07. Management of the Ostomy Patient - General Principles Postop Care - Patient Education

In this class we are going to talk about management of the ostomy patient again from a general perspective focusing primarily on patient education. What are the critical elements we need to include? So we are going to discuss information to be included in the education plan for a new ostomy patient and we are also going to identify principles of supportive counseling because the whole time we are doing education we are also providing support. So we start we want to educate the patient about normal stomach characteristics. Most of these people have never seen a stomach before and don't know what to expect and what's normal and what's not. Actually we frequently find that a guided tour of the stomach is a nice way to move the patient into beginning participation in self care. So we want to explain to them that it's normal for the stomach to be red and moist, that that's the color it should be, that it means it's healthy, it's got a good blood supply, that they shouldn't worry as long as it's red and wet, they should only worry if it starts turning dark or getting dry. We want to again explain to them that there are no nerve endings in the stomach so even though it looks like it would be painful and sensitive, in actuality they can clean around it, they can gently clean across the stomach itself and they won't feel anything. If they hug somebody really tightly it won't hurt if they wear snug clothing it won't hurt. A very important point to include is the fact that the stomach is initially swollen and that that swelling will gradually resolve over about six weeks. That means that during the initial six to eight weeks they'll need to measure the stomach at each pouch change because they'll be constantly changing the size of the opening. But once the stomach stays the same size for a couple of weeks most people can order their pouches pre-cut which makes self care easier. We also want to explain to them that it's not unusual to get minor bleeding with cleansing because we don't want them to be freaked out and worried that something terrible is going on. We want to say to them, if you take a self-cloth, a self-paper towel, clean around the stomach, very common to see a little bit of blood on your cloth on your self-paper towel. Don't worry, stomas do bleed because they have a very rich blood supply. Now if it's dripping blood into the pouch that's abnormal. But if you're just seeing a little bit of blood where you clean the stoma that's okay. We've already said that one of the critical self-care skills we consider this a survival skill is when and how to empty. When to empty. We want them to get in the habit of emptying their pouch when it's about halfway full. Because they get in the habit of emptying when it's about halfway full, that builds in a little bit of response time because sometimes they're going to recognize that the pouches halfway full and it's going to be 15, 20, 30 minutes before they can get to a restroom. Okay. We don't want them to get in the habit of waiting until the pouch is almost at capacity because then if they can't get to a bathroom in time, they risk leakage. When the pouch overfills, it will start to undermine and pull the pouch away from the skin. So we've got to emphasize to them the importance of kind of monitoring their pouch for fullness and getting in the habit of emptying when it's about halfway full. And then how to empty. Well with the urinary pouches, very, very easy. You just open the spout, drain the pouch, dry off the spout and close it. Now a common question from men with a urinary pouches, do I sit? Do I stand? You can do either. So the pouch is going to hit right at growing level. So they can stand in front of a urinal and drain the pouch. They can sit on the toilet and drain the pouch. With a fecal pouch, with a drainable pouch, you are going to teach them to hold the pouch up so that all the drainage falls down. So hold the pouch up, open it, pinch the ends together, and then lean forward and drain it directly into the toilet. Now one thing that's helpful to a lot of people is to sit backwards on the toilet so that they're actually facing the wall and so they have more room to manipulate. You might suggest that the patient sit backwards, hold the pouch up, open it, pinch it, drain it, and then clean the outside and the inside with toilet paper with a wet wipe. They can then add deodorant if they wish and close the spout. One additional tip you can give people is that it's frequently helpful to put toilet paper down into the commode before they empty. That's just to prevent splashing. The other survival skill is changing the pouch. So the two things we spend so much time on initially is when and how to empty, when and how to change. Most people change their pouch one to two times a week. Typically we start them off with three to four day intervals so we might tell them to change them Tuesday and Friday, Wednesday and Saturday, Thursday and Sunday. And then once they're very comfortable with that, if they're doing well, they can try to stretch it out a little bit. We never want them to go longer than a week because the barrier is formulated to adhere to the skin for about a week. After that point, the seal becomes progressively less secure. So you want them to think, I'm changing my pouch once or twice a week, also you want them to know that if they experience any burning, severe itching, any leakage, they should change immediately because you never won't stool or urine trapped on the skin. Now you want to keep the basic pouch change procedure as simple as possible. So we've kind of outlined a basic procedure here, wash your hands, gather your supplies. Use your old pouch using gentle push pull techniques. So you pull up on the pouch, push down on your skin, pull, push, pull, push, also very helpful to use an adhesive releaseer. One of the new silicone adhesive releases makes it much easier for them to remove the pouch without trauma. They're going to clean their skin using warm water and a soft cloth or a very soft paper towel. And then they're going to place a paper towel underneath their stoma to catch any leakage. Now they have their old pouch off, their skin is clean and dry. They're going to take the measuring guide that we give them, which is a piece of paper with a bunch of circles or ovals and they're going to measure their stoma. And they're looking for the opening that clears the stoma, but minimizes exposed skin. Then they're going to trace that opening onto the back of the pouch or the wafer and cut it out. And they'll take the backing off, apply a little bit of paste or a barrier ring to the cut edge if needed, center it, press it into place, and then close this pouch. We want to keep the pouch change procedure as simple as possible. We want to demonstrate it to them. Then we want to help them do it themselves. And finally, we want to stand by and watch them so that we know when they go home that they can change the pouch, the patient and the caregiver can work together to change the pouch. We want to teach all of our patients how to manage minor peristomal skin breakdown. And this is called the crusting procedure. Hopefully, they won't need to know this, but most patients with an ostomy at some point in time will need to use this crusting procedure. So what we tell them to do is after they clean their skin, take their ostomy powder and sprinkle a small amount of ostomy powder onto any areas of irritation. And then dust off the excess. You don't want a blob of powder. You want just a thin film of powder to adhere to the wet damaged skin. and to form a protective layer. At that point, you can either proceed to apply the pouch or you can apply a thin layer of an alcohol-free liquid skin barrier. Usually a spray, you can spray with an alcohol-free liquid skin barrier or you can take an alcohol-free wipe and blot over the powder. And what that does, it puts a plastic film on top of the powder that sometimes gives you a better pouching surface. A lot of times patients get confused, what comes first, the powder or the spray? I got home, I couldn't remember. So we tell them it's like the alphabet. P comes before S, powder comes before spray. And one of my friends told her patients, when you get done, your skin should look like a sugar doughnut. So you should see that little bit of powder underneath the spray, but it should not feel like a sugar doughnut. You should not feel the powder. You can see it, but you shouldn't feel a lot of powder. And then, if the damage is severe, a lot of clinicians will do a repeat layer. So they'll do powder, dust off the excess, spray, let it dry, powder, brush off the excess, spray, let it dry and proceed. Most ostomy nurses consider this an essential element of patient education. Most of us believe that every patient should know how to treat minor irritation and should also know to call their ostomy nurse if this doesn't take care of the problem. There will be many lifestyle issues that patients have questions about. And of course, the number one is bathing. So do I have to take my pouch off to get a shower or to get a bath? Is it okay to shower or tub bath with my pouch on? You can shower or tub bath with a pouch on or off. If you shower or tub bath with a pouch on, you get out. You dry off with a towel. You dry your pouch off with a towel. And then you can use a hair dryer on a cool setting to dry the tape border and the fabric back into the pouch. You can also shower or bath with the pouch off. But you need to know when your stoma is the least active because you don't really want to be pooping and peeing all over everything in the shower. So you want to pick a time when your stoma is pretty inactive if you're going to shower with a pouch off. What a lot of patients do. They routinely shower or tub bath with the pouch on. On the day that they're going to change their pouch, what they do is they take the old pouch off. They shower. And then they get out and put the new pouch on. Also you should know, as you can see from the left side of your slide here, that they do make shower guards for pouches. So you can get a raincoat for your pouch if you wish. Clothing. Clothing is a huge concern for most people with an ostomy. They don't want their pouch to show. They want to pick and choose who to tell about the fact that they have an ostomy. So they want their pouch to be low profile, very discreet. They also want a sense of security, so a lot of people will tell you that when they have secure underwear, snug underwear, or a snug band, that they feel much more secure because it's holding their pouch in place. So a rule of thumb is, as you see on the top left, you can tuck your pouch into your underwear and have your underwear hold the pouch securely against your skin. Or you can choose to wear your underwear and your jeans or slacks underneath the pouch and let the pouch come out on top. In general, people find that if they wear a snug layer right next to the body, it flattens the pouch out and holds it securely in place, and then they can wear a loose outer layer to help conceal the pouch. I also want you to know that there are now a number of commercial products and I want you to go online, you can look up underwear for ostomy, support bands for ostomy. So you can see here that there's underwear and abdominal bands that are designed to secure and conceal the stomach. Options, ostomy secrets, stealth belts. Those are some of the companies that make products just for ostomy patients. So ostomy secrets was actually developed by a young woman with an ostomy. She wanted underwear that kept her pouch flat and snug and that made her feel very comfortable in whatever clothing she chose to wear. So she worked with a manufacturer to develop ostomy secrets underwear for men and women. They have multiple styles, they even have thongs, and every one of them has an inner pouch for the pouch to keep the pouch off the skin. You see that purple wrap? There's also several companies that make abdominal binders, abdominal wraps that provide a lot of support, security, and concealment. So many, many choices out there. I think you also see the stealth belts. So encourage your patient to go online to look at the different options, give them a list of choices of manufacturers, encourage them on a day when they're feeling better to kind of have a try-on day where they try different approaches. They try tucking their pouch in, they try leaving their pouch out, they see what makes them feel most comfortable and most secure. What about managing away from home? What about when you're at work? What about when you're out in public? You're in a store, you're in a grocery store, you're at the mall, and you have to empty your pouch. One reason we want people to get really good at emptying their pouch so they feel very confident, emptying in a public restroom. Most people carry a little deodorant spray and their purse or their pocket that they can use in the restroom. I will share one thing from a mistake I made. If you're going to suggest a room deodorant, try it yourself first. Try it with some patience before you recommend it. I remember having a sample of deodorant spray it had an orange scent. I had a gentleman, he's like, "Dorthy, all of these deodorants, they all smell like flowers." I don't want to smell like flowers. Isn't there something that's a little bit more manly? I'm like, "Well, there's not a lot, but I have this new one that's orange-centered." He's like, "Okay, I'll take that one, I'll try that one." I'm like, "Okay, I haven't really used it, you have to tell me." He came back and he's like, "So you know that deodorant spray? You gave me?" I'm like, "Yeah, how'd it work?" He's like, "Well, when you just spray it into the air, it smells really good like oranges, right?" I'm like, "Right, that's what I thought." He's like, "Yeah, but when you really need it, it smells like somebody pooped in an orange grove, so it doesn't really work." So try things before you recommend them. The other thing you want to teach patients is to always have an emergency kit. There are some commercial kits available, so they can literally go online and find a commercial kit that they can always carry with them, but they can make their own. They can take a gallon-sized ziplock bag. They can put in a pouch that's already cut out, a barrier ring if they need that. They can take a quartz-sized ziplock bag and put moist paper towels. And then if they do have to change when they're away from home, they can just go into the bathroom, into the stall, open up their ziplock bag, take off the old pouch, put it in the ziplock bag, take their wet paper towels, clean their skin, take the toilet paper, dry their skin, and then take their precut pouch that's in their emergency kit and put it on. And maybe it's not perfect, but it's going to get them home and it's going to add to their security, leaving the house. What about traveling? So a lot of people are really nervous about resumption of travel, people with us to me is travel everywhere. They travel by plane, they take cruises, they travel by train bus, they take international flights. So these are some basic guidelines. If you're taking commercial transportation, you should keep your supplies with you in your carry on. Don't put it in checked luggage because checked luggage is exposed to tremendous extremes of temperature, plus it gets lost. Make more supplies than you think you will need. Take at least twice as many as you think you will need. If you're going to be on a prolonged trip, you're going to several different countries or whatever. See if you can identify supply points where you're going to be, just in case. Also if you have any concerns at all about the safety of the water, don't take a chance, take bottled water, that's always safe. And finally you should know that the United OSME Association of America provides little cards for individuals with ostomy that you can show at the screening point, and that will assure you private screening. So yes, people travel, yes you can travel, and there's a lot of resources out there to make it easier and more comfortable. What about resuming social and sexual activities? We want to see people getting back into usual activities somewhere around six to eight weeks post-operatively, going back to work, going out to eat, going to the movie, going out with friends. Now people will tell you I felt so nervous. The first few times I went out of the house, I was so nervous, I didn't even have a good time. I was so nervous, I couldn't even try anything going at the mall, I just kept going to the bathroom and checking my pouch. You know what, that's totally normal, that's okay. That's what's involved in acquiring comfort with a new form of elimination. What matters is that you pushed yourself and you went out the door and you went and did something and you came back. And the second time you do it is a little bit easier and the third time easier than that. Now many patients, most patients have restrictions on lifting. So you need to know what your restrictions are, you need to talk to your surgeon. Can I go back to the gym? Yes. When? Probably at six weeks. Can I lift weights? No. Can I ever lift weights? Maybe, maybe not, the surgeon's going to make that decision on an individual basis. But yes, you can go to the gym, yes, you can travel, yes, you can hike, yes, you can camp. All of those things. But you need to get medical clearance before you do anything that's stimulus at all. What about sex? Most people are ready to resume sexual activity about six to eight weeks post-operatively. There's a lot of specific issues that come up for individuals with an estimate and we will cover that in a later lesson. And then one thing you want to be sure you talk to your patient about is where are they going to get equipment? Where do they get their supplies? You can't walk into CVS and get supplies. So you need to give them a list of their supplies. You need to give them a list of vendors, a list of suppliers, DME providers. They probably will need a prescription. So you want to give them information about that. You want to give them information about ostomy nurse follow-up. And you want to let them know about resources in the community. For example, UOAA, so they can go to www.uOAA.org and find a lot of online resources. And they will also find information about face-to-face support groups, incredibly helpful to connect people to other people with an ostomy. So one, they know they're not alone. And number two, they have a support group that they can reach out to if they have a specific question or concern. Any patient with a fecal diversion, whether it's a colostomy or an Iliostomy, needs information about managing gas and odor. We talked a little bit about the fact that gas typically occurs somewhere between four and six hours after you eat a gas-producing food. We'll talk more about that when we talk specifically about colostomy management and Iliostomy management. I will tell you this. You need to explain lag time to patients. That's what we just talked about. That four to six hours. You need to help them identify gas-producing foods. You need to teach them the muffling technique. And the muffling technique is if I can feel gas moving around and I'm around other people, I can take my arm or my hand and kind of press it against my stoma. And that just eases it out and makes it much quieter. So instead of popping out, it just eases out. Finally, you want to help them practice what they're going to say if they have gas unexpectedly. And one thing in their favor is that no one expects you to fart frontside. So they can say, "Oh, I didn't get to eat lunch. My stomach won't stop growling." And nobody's going to challenge them on that. It sounds different and that's a very plausible explanation. And it gets them out of a difficult situation. So we'll talk more about gas and odor, but those are very common concerns for patients with either Iliostomy or colostomy. Again, you want them to know the pouches or odor proof. There are deodorants that they can add to the pouch every time they empty to reduce odor with empty. Dietary and fluid modifications are extremely variable. It determines, it's determined by the type of ostomy they have, so we will come back to that. We'll talk about that. We'll talk about Iliostomy management. We'll talk about it. We'll talk about colostomy management. And then prevention and management of complications also very diversion-specific. We said the whole time we're teaching patients and helping them to move forward toward independence we're providing supportive counseling. This patient has a lot on their plate, a lot to deal with. And the whole time they're trying to learn, they're dealing with their feelings about looking down and seeing a stoma. Looking down and seeing stool or urine, they're not used to that. And they have lots of concerns about, is it going to show or people going to know or people going to treat me differently? How do I manage? How do I manage telling other people? Should I tell? Do I have to tell? Who do I tell? So we know that this is a very difficult period for every one of our patients. They're adapting to a change in body image, how their body looks. They're adapting to a change in body function. They don't feel good. They're having to learn all these things. It's a very scary time. There are many things that impact on an individual's ability to adapt. Most of all, they're a basic personality and coping style. So some patients, they're going to do well with or without us. They'll do better with us, but they would get by without us. I remember a patient I had way back and she had her bladder removed, owned a Caribbean island. And the doctor had told her when she had her surgery, he said, "I know what's wrong with you. You have bladder cancer." And I know what to do about it, I've got to take out your bladder. But here's the problem, he's like, "I'm going to have to make an opening on your abdomen for the urine to come out." I know how to do that, but I don't know how to take care of it. And nobody on this island knows how to take care of it. And she's like, "Well, I tell you what, Doc, you saved my life and I'll figure out how to live it." Well she was such an upbeat kind of person that in the two weeks while she's awaiting surgery, she went down to the delivery shop where they made things for horses. Now remember, this is like 30 years ago and she's like, "Okay, this isn't going to make any sense to you, but I'm just wondering. I know you make all these lather devices for horses. And I'm going to have this thing on my belly. urine's going to come out, I've got to figure out some kind of bag to wear. I'm wondering, do you think you could make me a ring with a flange on it like a leather ring with a flange and some little belt hooks on the side?" And they're like, "Yeah, yeah, we can do that." And then she went next door. to the apothecary, the drug store, and she's like, "I've got to figure out some kind of bag situation. I don't want an animal bag. I don't want a douche bag. Do you think you can help me figure out some kind of bag?" Oh, yeah, we're going to help you. You see what she did? She solved her problem. She enlisted people because she was very open, very upbeat. In prison, she had a whole team. I met her when she came to Atlanta to visit her daughter, had a heart attack while she was here, ended up in the hospital, and the nurses were all like, "You've got to come see what she's wearing on her eyes to me." So I went to see what she was wearing. I was much more interested in talking to her to see, "How did you develop this?" She came up with a unique solution to her problem. So she was going to be OK with her without help. But there's other people who have been beat down by life. They feel very ill prepared to deal with anything, and even with a lot of support and a lot of assistance, they're going to struggle to be OK. Support makes a difference. The support we provide, the support their family and friends provide, the support we can provide them through the ostomy association, and finally, manageability of the stoma makes a huge difference. If they can keep a pouch on without difficulty, if they feel confident that their pouch is going to work, they're going to do a lot better than somebody who's worried every single minute of every single day that their pouch is going to fall off, that they're going to have a leak. What are the things we can do to help? We can provide empathetic management. We can ask about their concerns. How are you doing? What are your big concerns about when you go home? What worries you the most? Then we want to listen to what they say back to us, hear them out, acknowledge that this is a tough time, and offer our assistance in problem solving. These are very important concepts. We'll come back to them later, but we wanted to introduce them here at the beginning of this course. If I have a patient with severe or prolonged depression, I'm not going to hesitate to refer that patient to a psychiatrist for medications and higher level counseling. In summary, during the acute postoperative phase, this encompasses both hospital care and home health care. We're going to provide ongoing assessment of stomaviability and function. We're going to work hard on an ongoing basis with the patient to establish an effective pouching system. We're going to focus a lot of attention on survival skills. How to empty, when to empty, how to change, when to change, how to manage skin irritation, dietary guidelines, all of those things, and throughout it all, we're going to be assessing their emotional status, asking them how they're doing, asking about their concerns, and providing ongoing support. Thank you very much.