Speaker 1This class is a follow-up to our previous discussion of rehabilitative care for the ostomy patient. In the last class, we talked about the adaptation process, factors impacting on an individual's response, and also how we go about assessing a patient's progress and adaptation. In this class, we're really going to focus more on our role as ostomy nurses. What are the things that we can do that promote ostomy patient adaptation? So we'll talk about major concerns. Studies have been done to identify major concerns for the patient with an ostomy. We'll talk about our role. And education. And we'll also talk about our role in counseling, specifically our role in assessing levels of depression, anxiety, and providing appropriate interventions and referrals. So when we have done studies and we have queried new ostomy patients about their major concerns, it's exactly what you would think. So they're worried about their ability to do self-care, to get a pouch on, to keep it on, to empty it without making a mess. They're worried about leakage issues. They're worried about odor. They're worried about noise. And as they will tell you, it all comes down to, I don't want to be embarrassed. I want to maintain my dignity. A lot of people are worried about, is this going to show through my clothing? How will I know? Do I need to adapt my clothing? Then they're also worried about dating and sexual activity. Am I going to be able to resume sexual activity? Is anybody going to want to have sex with me? How do we manage the stoma? How do we manage the pouch? Sports, travel, leisure. Can I do those things? What adjustments do I have to make? A pervasive thing is I just don't, I don't feel the same. I don't look the same. I don't feel the same about myself. I don't feel as attractive. I don't feel sexy. I feel kind of dirty when I look down and see the pouch. So we need to address those issues. And finally, and this didn't show up in earlier surveys, but is showing up consistently in later surveys, is economic issues, the cost of supplies. How am I going to manage that? So we've already said, what's the goal? And then we're going to talk about how do we manage the cost? So we've talked about our role in pre-op teaching and stoma site marking. We've talked about the critical importance of establishing a secure pouching system and how we go about doing that, about our role in helping patients problem solve any issues with pouching, any issues with leakage, with peristomal skin complications. We have to assess their progress and adaptation on an ongoing basis, so critical questions to ask, we'll quickly review those. A very important intervention that we provide is ongoing education. So we teach them how to manage the ostomy. We provide education regarding complication prevention, and we also provide supportive counseling and critical care. Critical referrals. So those are the things we're going to talk about in this class. So let's talk about questions we should be asking. We're always assessing this person's progress and adaptation. So how do we do that? We ask critical questions. A great question to ask pre-op is when you think about this surgery, when you think about possibly needing an ostomy, what are your biggest concerns? Have you been able to talk about the possibility of an ostomy? Or if we know they're going to have an ostomy, have you been able to talk about this operation? Have you been able to talk about the ostomy with the people who are close to you, with your sexual partner? What kind of concerns do they have? Are they able to provide you with support? Do you have any concerns? Do you have any concerns about the impact of this surgery and this ostomy on your relationship? When you look ahead, where do you think you'll be? How do you think you'll be doing? Post-operatively is a follow-up of all of those discussion points. How are you doing? How are you feeling? Who's emptying and changing the pouch? You want to get at level of self-care. What problems are you having related to the ostomy? How are you doing in terms of getting back into your usual activities? Are you getting ready to go back to work? You getting ready to go back to school? Have you resumed any of your social activities? Have you resumed sexual activity? What are your concerns when you think about going back to school, back to work, going out to eat, going out with friends? Resuming sexual activity? What are your concerns? What's your support group? And are you in touch with anyone else who has an ostomy? Would you like information about support groups, about connecting with other people with an ostomy? And how can I help you? So we've already said that mastery of self-care is the first level of activity. It's the foundation of self-adaptation and that it actually is foundational to the other levels. So it's the first thing we want to help our patients achieve, independence and self-care. So we're going to, from the beginning, even in our pre-op discussions, we're providing basic information. Let me show you a pouch. Let me show you how this pouch is emptied. So I'm going to show you the procedure of pouch change and the procedure for pouch change post-operatively. What do I start with? How to empty. When and how to empty. What do I move to? When and how to change. So first I demonstrate the pouch change procedure. Then I get you involved. Okay. I'm going to let you take off your pouch this time. Here's your releaser. Remember to do push-pull. Okay. You're doing great. You're doing great. Every time, I have you do more until you're independent and self-care. We're going to teach you the crusting procedure. Here's what you're going to do if you develop any little areas of breakdown. I'm going to teach you first aid. In one of our teaching sessions, I'm going to go over with you where and how to obtain supplies. All of this is going to be written down for you, but I'm going to review it with you so I want you to know that one of the things you need to do during your first week home, you need to pick up the phone. You need to call this vendor, this durable medical equipment dealer. You need to set up an account, and you need to order your supplies. I want to make sure that you have information about community resources. Who do you call if you have a question? Where can you go if you're having issues with? Your pouch not staying on or with itching around your stoma? And then I'm going to give each patient specific information about complication prevention. That's going to vary based on the type of ostomy they have. They have a urinary diversion, I'm going to be talking to them about prevention and early recognition of urinary tract infection. If they have an ileostomy, I'm going to be talking to them about prevention. They have a colostomy, I'm going to be talking to them about preventing dehydration, preventing food blockage. If they have a colostomy, I'm going to be talking to them about preventing constipation. And we've talked about those things in our classes on specific diversions. Now a huge part of my role as an ostomy nurse is patient education because I want to provide them with the tools to manage their ostomy long term. I need to consistently adhere to principles of effective education and the first principle is people learn much more readily if they are ready to learn, so in the past we routinely waited until patients were watching care procedures till they were asking questions and we didn't really introduce active teaching until patients demonstrated readiness to learn but now we all live and work in a short stay environment and we can't always do that sometimes we have to kind of push people so sometimes we have to say i want to demonstrate to you how to change your pouch today i'm going to take it off i'm going to do the pouch change procedure but i'm going to explain every step or today i know you might not be quite ready to look at your stoma but i'm going to review some things that you have to know now if you are ready to look at your stoma i'm ready to take you on that tour so you see how now instead of just waiting for people to get ready we push them toward readiness and we introduce content we think they can handle so if you're not quite ready to look at your stoma let's talk about options for pouches let's talk about one piece versus two piece let's talk about clear versus opaque because that moves you into decision making which moves you into accepting responsibility but doesn't force you to look at the stoma if you're not quite ready we definitely should delay teaching if the patient's very upset or if they're in physical distress if they're in a lot of pain no nobody can learn when they're in a lot of pain if they're very nauseous if they're extremely fatigued so you're going to reschedule your visit for a time that is going to work more easily effectively for that patient we've already said you focus your initial teaching on survival skills when in how to empty when in how to change how to obtain supplies and i want to emphasize the last bullet point try very hard to avoid overload we have so much we want to tell our patients so much we want to teach them that it's very easy for us to overdo it but remember the patient you've all been in situations where you could only handle so much information so it's better to give them a little and have them retain it than to give them a lot and push them over the edge into frustration watch for cues they've had enough they stop asking questions they turn away they close their eyes they sigh when they've had enough you need to stop and you can ask them do you think you've had enough for today are there other things you wanted to go over they'll tell you other things to help you be more effective as an instructor as a teacher one is key procedures as simple as possible if i'm stressed if i'm anxious if i'm recovering from surgery it's a lot easier for me to learn a four to five step procedure than a nine to ten step procedure so keep it as simple as possible know up front you're going to have to repeat it it's not like well i told her that how many times it's going to require repetition i'm under physical stress and emotional stress and this is new content for me so remember the last time you had to learn something new and remember how helpful it was if your teacher kept it simple avoided overload provided repetition also we know from studies that if we involve multiple teaching learning strategies we're usually more effective so you want to explain you also want to demonstrate it might be helpful to have me work with a teacher who's a teacher of the arts who's a teacher of the arts who's a teacher of the arts who's a teacher of the arts who's a teacher of the arts who's a teacher of the arts who's a teacher of the arts who's a teacher of the arts who's a teacher of the arts who's a teacher of the arts who's a teacher of the arts always helpful or almost always helpful to provide step-by-step written instructions that i can take home but in the end when it comes to psychomotor skills it's got to be about demo and return demo you know as a nurse did you learn psychomotor skills from watching a video from reading it in a book no you learned psychomotor skills from reading it in a book no you learned psychomotor skills from reading it in a book no you learned it because you had to do it that's how patients are going it because you had to do it that's how patients are going to learn so how are they going to learn to learn so how are they going to learn to learn so how are they going to learn to empty you show them and then you have them do it to empty you show them and then you have them do it how do they learn to change you show them then how do they learn to change you show them then how do they learn to change you show them then you involve them and finally you let them you involve them and finally you let them you involve them and finally you let them demonstrate their ability to change that demonstrate their ability to change that demonstrate their ability to change that pouch while you keep your hands pouch while you keep your hands in your pockets it's hard you're constantly evaluating their you're constantly evaluating their you're constantly evaluating their learning learning learning okay have they mastered pouch emptying okay have they mastered pouch emptying okay have they mastered pouch emptying do they know when their pouch needs to do they know when their pouch needs to do they know when their pouch needs to be emptied be emptied be emptied can they take the pouch off correctly can they take the pouch off correctly can they take the pouch off correctly can they measure and cut or is that can they measure and cut or is that can they measure and cut or is that something i need to reinforce something i need to reinforce something i need to reinforce so which elements of this teaching plan so which elements of this teaching plan so which elements of this teaching plan have been been accomplished have been been accomplished have been been accomplished which elements are still in process which elements are still in process which elements are still in process and we've talked over and over but we and we've talked over and over but we and we've talked over and over but we can't say it too many times can't say it too many times can't say it too many times their time in the hospital is just one their time in the hospital is just one their time in the hospital is just one component of their care component of their care component of their care and one of the most important and one of the most important and one of the most important responsibilities we have is to assure responsibilities we have is to assure responsibilities we have is to assure appropriate follow-up appropriate follow-up appropriate follow-up so you're going home tomorrow are you so you're going home tomorrow are you so you're going home tomorrow are you set up with home health set up with home health set up with home health you're discharging them from home health you're discharging them from home health you're discharging them from home health do you have them set up with an do you have them set up with an do you have them set up with an outpatient clinic now there are a lot of great audio now there are a lot of great audio now there are a lot of great audio visual visual visual materials out there materials out there materials out there you'd need to follow some defined you'd need to follow some defined you'd need to follow some defined guidelines before you start handing guidelines before you start handing guidelines before you start handing things out to patients before you give things out to patients before you give things out to patients before you give them this booklet for you before you recommend this YouTube video. First of all, if you're thinking about sharing it with a patient, watch it first. Make sure that there's nothing in there that you disagree with. Also make sure that the content is effectively presented, that they follow those guidelines. Keep it simple, keep it organized, provide appropriate repetition. If it's print material, remember it should be fifth grade reading level and you can run a reading level check on your computer. Is it fifth grade reading level? Even if I have an advanced degree, early post-op, the simpler the materials the better. So the general recommendation is fifth grade reading level, 14 point font, simple, simple layout, simple illustrations. So critically review materials that you're going to provide your patients. You're all working in a short stay environment, so here are some additional things. You can videotape teaching sessions on the patient's phone. That's frequently very helpful. Many times they'll suggest it if you don't, but if they don't suggest it, you should. You should be aware that all of the major companies, Convitec, Coloplast, Hollister, they all have discharge kits, which are wonderful. They provide written materials, they provide samples, they provide a little carry kit. You can individualize what is included in that discharge kit, and so you can sign the patient up. You can get their permission to share their address and their name and their phone number, and if they give permission, you can sign them up. You can either fax a sign-up form or sign them up online for a discharge kit. So definitely they should get a discharge kit from the company whose products they're using at the time of discharge. So minimally they should get at least one discharge kit. If you think they would benefit and care for you, you should sign them up. And if you think they can handle more than one, then you can sign them up for more than one company's discharge kit. But remember, for some of your patients, if you provide them with multiple samples, multiple discharge kits, multiple versions of written materials, it can just add to their confusion. So use your best judgment as to what's best for this patient. If you have a patient outpatient follow-up, they should have someone to call if they have a problem. Now we have talked to some extent about teaching adaptations based on developmental stage, so we'll go through this very quickly. We've already said when you're dealing with infants, you're going to focus on teaching the parents. You're going to keep the pouching system very simple because they'll probably have to change it every one to three days. You also want to suggest clothing adaptations to keep the baby's hands away from the pouch. They'll pull those pouches off. So suggest onesies that protects the pouching system. And we've already talked about the critical importance of supporting the parents. How are you doing? I know you've got so much you're dealing with. How are you feeling? Are you sleeping? Are you eating? What concerns do you have? How can I help? For toddlers and preschool children, they're very curious and they're very active. So a couple of things you want to be aware that there are teaching dolls. So you can get a teaching doll, you can pouch the doll, or you can pouch the stuffed animal. So play therapy is very helpful in helping them understand what's being done and what's going on. Also, you have to constantly adjust their pouching system and their clothing to maintain a secure seal when they're crawling, when they're pulling up, when they're walking. Geriatric patients usually need shorter, more frequent sessions. They're more likely to get overwhelmed and overloaded. So don't try to teach them everything in one session. If today you're covering emptying and pouch selection, that's probably enough. Cover emptying, when to empty, how to empty. Looking at this one-piece pouch and this two-piece pouch, do you have a preference? Then tomorrow we're going to go over the pouch change procedure. And on the following day, I'm going to review diet and how to order your supplies. Spread it out and provide repetition. We've already said, written, and processed. Should be large print, at least 14-point font. Black ink on matte white paper is easiest to read. You want simple procedures, simple instructions. You want simple illustrations. And work with your patient to select the best products. Because they might be dealing with arthritis and reduced dexterity. Reduced eye-hand coordination. So are they able to measure their stoma or do you need someone else involved for that? Can they cut their pouch out or do you have to make alternative arrangements until they can get pouches pre-cut? Can they see to center their pouching system or do you need someone to assist with that? So work with the patient to determine any special needs and consider cost. Now you're going to have patients with visual loss. Some of your patients will be legally blind. Others will tell you it's hard for me to see. I'm not sure I have it lined up correctly. So if you have a patient with visual impairment, your primary teaching approach is verbal. Talk through a lot of things and hands-on. So we're going to work with a model. And then we're going to have you transfer that to yourself. I'm going to let you feel your way through taking this off, cleaning your skin. Can you see the stoma? Okay, let's see how well you can center to apply the pouch. You're going to come up with strategies to fill in gaps if they have trouble seeing. One thing that can be done for patients who have trouble centering the pouch, you can actually create a cardboard tube. You can take a piece of cardboard and roll it up so it's the same diameter as the stoma and then tape it together. And then you can have the patient put that cardboard tube over the stoma and fit the pouch down over the cardboard tube. So that can be done when you have a patient who cannot see to center the pouch, and maybe they live alone. So they've got to be able to come up with a way to center and apply their pouch independently. What about patients with hearing loss? Well, then you're going to rely heavily on visual. So they're watching what you do, and you're having them repeat procedures, repeat steps. Also, if they have a hearing aid, you make sure that for each teaching session the hearing aid is in and on. If they don't have a functioning hearing aid, you can use a stethoscope. You can speak through the diaphragm. So you can put the ear pieces in their ears, clean them, put them in their ears, speak through the diaphragm or the bell so that the sound is augmented and they can hear you. Very simple strategy for improving your effectiveness in teaching so you're not screaming at the patient. Okay. If they use sign language, most hospitals have sign language interpreters, so you would want to get a sign language interpreter if that is available to you. And one of the most important things in working with patients with hearing loss is to constantly seek feedback as to what they heard. What do you remember out of what I told you? Because it's human nature, we try to fill in gaps, we try to figure out what you said. Usually we're not right. So I want to cycle back around. Out of everything I told you about changing your pouch, what do you remember? What's the first step? What's the second step? So that you can identify any gaps and correct those gaps, fill those gaps. Sometimes you're going to have patients with psychomotor issues. So I've had patients with chord injuries. Some of them were quadriplegic, but they wanted to be as independent as possible. So one of your best resources is an occupational therapist. They can come in, they can figure out what needs to be done. They can assess the patient's baseline abilities. And they're wizards. They come up with these great adaptive tools. So they'll come up with splints and things like that. They can do things that allow patients to empty their pouch when you thought there was no way they could do that. So if you're struggling to come up with an effective solution for a patient with psychomotor issues, consult your occupational therapist. Then you and the OT and the patient can work together to figure out what works best for them. Okay, so is it better for you to use a Velcro closure? Pouch? Or to remove a closed-end pouch and snap another one on? Or to use a clip pouch? Which one of those is easiest for you? Because we can do any of those things. Okay. Learning difficulties. In general, if a patient functions at a level of six years or greater, they can learn self-care. And it's up to us. When we have patients with learning difficulties, to first of all simplify the procedure. Secondly, write it down step by step so that anyone who is teaching this patient uses exactly the same order, the same terminology, the same expectations. Because how do we teach kids? We teach them with repetition. How are we going to teach patients with learning difficulties? We're going to use repetition. So we've talked about our role in education. The last thing we're going to talk about is our role in supportive counseling. So we want to always remember that that person in the bed, in the chair, not only has to learn how to manage this ostomy, they also have to come to the terms with the fact that we have modified their body. We've modified the way it looks. We've modified the way it works. They have modified continence. Everything's changed. This is a huge adaptation. And especially in our society, because we're not that open about elimination, especially about stool elimination. We're actually much more open about sex and sexual issues and sexual problems than we are about elimination issues. So it can be overwhelming for a patient to be trying to learn self-care and at the same time struggling with all of their feelings about everything that's happened to them. So you're going to move back and forth between being a teacher and being a counselor, between providing support and providing instruction. Obviously, you can't help me at all until you develop a relationship with me. So Everything we do to develop a relationship with our patients is important. From the moment we knock on the door and walk into that pre-op room, introduce ourselves, tell the patient why we're there. We want to communicate from the get-go that we're there to answer their questions and to provide any assistance we can. We want to, from the beginning, demonstrate sensitivity to the fact that this is a big operation and requires a lot of adjustment. We want to constantly pay attention to our communication skills. So you know, we communicate all day long, or we sort of communicate all day long, meaning we talk at people, we talk to people, sometimes we talk with people, which is the goal. Communication is our. We're very complex, multisensory, messy, and frequently ineffective way of sharing messages. And it's really hard to get it right. I mean, think about the people closest to you. Think about your significant others. How often does one or the other say, "You didn't hear me. Yes, I did. You said this." Well, you're parenting back the last thing they said. But they're probably right that you weren't really listening. How often does one or the other say, "That's not what I said." And so that's the person that knows you best. You would think communication would be a piece of cake with people who know you the best, who speak your language. But no, it's really hard. And what about when I'm talking to a patient who's dealing with major stress and a major threat? How difficult is that? How difficult is it to communicate effectively? They're going to be checking in and out. They're going to hear some of the things you say, not all of the things you say. So it requires a lot of focus on your part, a lot of repetition on your part, a lot of clarification on your part. We communicate both verbally and nonverbally. We have to work on our verbal communication because it's very easy for us to slip into physical language. And we have to work on our verbal communication because it's very easy for us to slip into physical language. Have you felt down or depressed a lot? Have you been unable to generate interest or pleasure in doing things? Do you want to just sit or withdraw or sleep? Ideally, you would use a validated depression screening tool like the Beck Depression Inventory or the Geriatric Depression Scale. But any time you have a patient where you're picking up on significant depression, you want to screen for suicidal thoughts, and you want to be very open. I can see you're very, very sad. I can see you're struggling. It doesn't sound right now like things are getting better. Do you ever think about hurting yourself? And if the patient has any suicidal thoughts or if they have persistent depression, you're going to refer them. And if in doubt, you're going to refer them. So it's very helpful to always have a list of psychiatrists to whom you can refer. And any patient with suicidal thoughts, the referral is urgent. So you refer right then with the patient in your office. If they have mild depression, well, some days I feel better. Like yesterday, I guess, was a better day. I got up. I got dressed. You know? I even thought about going to the mall. I didn't, but I thought about it. So there were times yesterday I felt pretty good. Today, I'm pretty much down in the dumps again. Okay, then we want to acknowledge, you know what? That is so normal. That up and down, feeling sad a lot, that's part of a huge adjustment that you're going through. The more open you can be, do you have people that you can talk to? Do you have a good support system? Who can you call if you're feeling really, really down? You can also encourage patients every day, set one goal. That shows a little progress as compared to the day before. So maybe it's walking out your front door and taking a one-block walk. And then tomorrow, it's two blocks. Maybe it's, I'm going to make myself go to the grocery store, even if I only get two things. I'm going to make myself go. Just to show myself I can do it. Encourage people to be their own checkpoint so that when they have catastrophic thoughts, very negative thoughts, that they challenge themselves. Like, okay, it's probably an overstatement if I say this is absolutely the worst thing that could ever happen to anyone. Okay, it's probably not the very worst thing. It seems pretty bad to me, but it's probably not the worst. Okay. Okay. Okay. Okay. Okay. Nobody's ever going to want to do anything with me, go anywhere with me, have sex with me. Well, that's probably not true either. That's probably an overstatement. So if they can start to check their own negativity, that's a step forward. And again, make sure they're connected to other people who have been through this, who are going through this now. If they talk to other people who have an ostomy, they're going to be talking to people who get it. And if they're not, they're going to be talking to people who are not. And who can provide realistic feedback that is going to be very valid. What about anxiety? So you know how totally disabling anxiety can be. So you're just worried. You can't focus. You can't come up with a management plan. You're worried your pouch is going to leak. You're afraid to go anywhere. You're afraid to do anything. And that worry persists even though, you know, you haven't had any leakage for the past three weeks. All of your pouches have stayed on four days. You've done routine pouch changes. But you're still so, so worried. And you can't really focus on anything except this ostomy. So every five minutes, you're checking your seal. Every 30 minutes, you're going to the bathroom to see if it needs to be empty. Okay, now at this point, the worry, the anxiety is starting to interfere with your life and with your progress. So you can say, you know, it seems like you're so worried that something bad will happen that you're really, you're really worried that something bad will happen that you're really, not able to move ahead. Do you agree? Is that what you think? Do you see it differently from me? You also want to differentiate between nervousness with a new activity. Like I went to the mall, but I went to the bathroom every 30 minutes and I was constantly checking. And you know what? I was too nervous to try anything on. That's okay. That's all very, very normal. But what if I'm so nervous that I won't leave my house? It's like I can't go to the store. I can't go for coffee. I can't go to the mall. I can't go to church because I'm too worried. I'm too worried that I'll have an accident, even though I'm not having accidents. Now we need to intervene. Now we need to refer. So if they have severe anxiety, it's preventing forward movement, getting back into their lives, getting back. Getting back into their daily routine, getting back into their daily life, getting back into their daily activities. We need to refer them. They're going to require medication and a higher level of counseling, but if they're just very nervous, we can do two things. We can say, first of all, when you get really nervous, what helps you? What kinds of things tend to calm you down and walk you off the cliff? And let's see if we can arrange for you to do some of those things. Let's talk about worst case. Let's say you went out for coffee, and all of a sudden you were pretty sure your pouch was leaking. What would you do? Do you have an emergency kit? You need an emergency kit. Everybody needs an emergency kit. That should be in your purse. What else? What would you be worried about? I would be worried it would show. Well, maybe you need to wear dark clothes. Maybe you need to wear a support wrap right around your belly so that you have extra layers of protection, just in case. You're going to not need that long term once you venture out and find that nothing happens. But initially, that might be helpful. What about frustration? Frustration is going to happen to everyone. Frustration happens to all of us. But you think when you're trying to master something, you're going to be able to do it. When you're trying to master something new, everything can tick you off and kind of push you over the edge. So sometimes you walk into a patient's room, and they're ticked off about everything. They didn't get my tray here on time, and then when they got it here, it wasn't what I ordered. And the coffee was cold, and the biscuit was hard. And then they came in to clean my room, and they made so much noise, I couldn't even hear the person on the other end of the phone. And almost always, the surgical team comes at 6 a.m., so I got up early, got ready, so I could have my list of questions, ask my questions. Did they come at 6 a.m.? No. So you see how everything is making me mad, everything. And it's just because I'm so frustrated, I'm so overwhelmed with everything happening to me. The surgery, the ostomy, having to learn all these care procedures, figuring out where to get supplies. Trying to come to terms with how this whole thing looks. It's just, it's just too much. So you can say, wow, you're having a really frustrating day. Walk me through some of those things. Just hear them out. Sometimes you just need someone to hear you out. Acknowledge, you know, this is a really hard time for you. Look at everything you're dealing with. So first of all, you find out you have cancer. Then you find out you have to have surgery. Then you find out you have to have an ostomy. That is so much. No wonder everything is pushing you over the edge. You've got so much on your plate right now. What can I do to help? So usually just hearing me out is what I need from you. Just acknowledge, yes, right now everything looks like crap, and thank you for acknowledging it. So in assessment, or anyway. In summary, we as ostomy nurses are always assessing our patients' progress and adaptation. How are you doing with self-care? How are you doing in terms of getting back into your life, resuming usual activities? How are you feeling? Strategies we use to help you get there. We teach you the things you need to know, which makes this ostomy much more manageable. So we teach you how to empty, how to change, how to manage minor skin irritation, where to get supplies, where your resources are, what dietary modifications do you need to make, all of those things. At the same time, we should be consistently conveying to you I know there's a lot going on. I know you're trying to come to terms with everything that's happened to you. I know you're trying to learn how to take care of this. At the same time, you're trying to wrap your head around the fact that you even have this. It's normal to have periods of sadness. It's normal to have periods of anger. It's normal to be very easily frustrated. I hear you. How can I help? And we always want to make sure that our patients are aware of resource groups, support groups, especially the UOAA or the International Ostomy Association. That's where they're going to connect with other people who have walked this same pathway, who have experienced these same issues, and who can provide them with real-life input and support and almost always. Humor and hope. And that's it for this class. Thank you.
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