The Ostomy Files: What is Preventive Ostomy Care?
Preventive medicine is at the forefront of payors’, regulators’, and providers’ agendas. It is important to examine what may be done to prevent the most common complications associated with ostomy surgery — complications that drive cost, decrease clinical outcomes, and negatively impact the patient’s quality of life.
Prevention is defined as “stop from happening; hinder; or make impossible.”1 The definition most applicable to ostomy care is “stop from happening.” What can be done to stop the most common complications — ie, irritant dermatitis, allergic dermatitis, pseudoverrucous lesions, unacceptable wear times, and persistent leakage — from happening?
The first step is preoperative stoma site marking to ensure the stoma is appropriately placed on the patient’s abdomen. Stomas must be located on a plane of skin that ensures adequate pouching and in a location that accommodates the patient’s self-care capabilities. In other words, the patient must be able to see the stoma to care for it properly and it must be in a place on the surface of the abdomen that promotes secure skin-to-skin barrier adhesion. The area around the stoma must be relatively flat, away from skin folds, scars, and creases in a standing, sitting, and supine position. Specialized ostomy nurses, such as Wound Ostomy Continence Nurses (WOCN), should teach colorectal surgeons, general surgeons, and urologists not only the importance of preoperative stoma site marking and its impact on the patient’s quality of life, but also how the process should be conducted. This education is particularly important in acute care centers where the services of a specialized WOCN may not be available to perform preoperative marking, making this procedure the surgeon’s responsibility.
The second step is to ensure the patient is fitted with an appropriate skin barrier that securely adheres to the peristomal skin for a predicted wear time and accommodates the character and quantity of the stomal output. Semi-formed or formed stool may be managed adequately with a standard hydrocolloid skin barrier, while urine, liquid stool, or extremely high liquid output from either a fecal or urinary diversion may benefit from extended-wear skin barriers. The topography of the peristomal skin also should be considered to determine whether a flat or convex skin barrier is needed.
The third and perhaps most significant step in preventing complications is educating the patient. Patients with a new stoma must understand what is normal before they can understand what is abnormal. They should be instructed that the peristomal skin should always be free of redness, irritation, or breakdown like any other areas on the skin and that if any of these appear, a healthcare professional should be contacted. Another area to be reviewed is cleansing the peristomal skin. Many patients who have not been taught correct procedures use alcohol, betadine, soaps containing oils, or other “cleansing” products that interfere with the adhesion of the skin barrier and contribute to skin breakdown.
Patients with urinary diversions should be taught how to monitor the pH of their urine at home, how to evaluate the character and color or their urine, how to maintain adequate fluid levels, and to report any gritty or “wart-like” areas under their skin barrier that may be a sign of leakage or the need for an extended-wear skin barrier.
Ileostomy patients need to understand how to recognize a food blockage. The United Ostomy Association (UOA) has excellent laminated cards on ileostomy blockage. One side of the card provides information on the signs and symptoms of a blockage along with steps a patient can take at home to attempt to relieve the blockage. The other side of the card contains information for the emergency room physician on how to conduct an ileostomy lavage. Each patient should be discharged with this information and a UOA Blockage Card with instructions to take the card to the emergency room when at-home remedies fail to relieve the obstruction or discomfort becomes extreme. These cards are available for bulk purchase at www.uoa.org.
Colostomy patients should understand their options for management — irrigation, dietary management, or closed-end or drainable pouches. They need to know they may still experience diarrhea or constipation as well as the appropriate steps to take should either develop. If they have a temporary diverting colostomy, they should be taught to expect the urge to have a bowel movement through their rectum and/or some rectal drainage. Without this knowledge, these experiences can be extremely anxiety-producing, causing patients unnecessary emergency room or physician office visits.
All ostomy patients, regardless of the type of surgery they have had, should be instructed about the potential or real side effects of their medications and appropriate methods to take their medications (ie, liquid, enteric coated, non-enteric coated) dependent on their individual surgery and/or other medical conditions.
In a column of this length, it is not possible to cover all the issues patients must consider in order for them to live as normal a life as possible after ostomy surgery. However, many of the complications seen in clinical practice could be prevented through appropriate preoperative stoma site marking, a team approach to care, and a comprehensive patient teaching program. In an era of prevention, ostomy patients must not be overlooked.
The Ostomy Files is made possible through the support of ConvaTec, a Bristol-Myers Squibb company, Princeton, NJ.