Many nurses are not sure about how to take care of an Ostomy patient. This article will help you to get answers to all your questions.
In the USA almost 100,000 individuals undergo Ostomy surgery every year. Fecal or urinary diversion surgeries are performed which allows the body to pass out urine and feces. Ostomies can be permanent or temporary. It can be continent or incontinent. In case of incontinent surgeries, you need to keep an external pouching system with you. In this article, we will mainly discuss incontinence and types of pouching systems.
During this procedure, a hole is created in the abdomen and a small or large intestine is pulled up to the abdominal wall and sewed there, resulting in a stoma. A stoma is an opening that allows the feces and urine to leave the body. The surgeon decides which portion of the intestine will be involved in the surgery depending upon the condition of the patient.
Some situations which demand Ostomy are:
- Colon cancer or rectal cancer
- Any trauma or injury in the bowel or rectum such as a bullet shot.
- Leakage in the bowel
- Cancer in the bladder
The most basic and common types of Ostomy are:
In the case of Ostomy, a patient can’t control urination or fecal discharge because there is no sensation or nerves around the stoma. Also, there is no sphincter present. This is the reason a patient can’t control the flow of the gas, urine, or feces out of the body.
This type of Ostomy ileum also called the small intestine is involved in the formation of the stoma. It allows the feces to leave the body. Ileostomy patients always require a pouching system to collect the feces, very acidic. If these feces come in contact with the stoma it may destroy stromal tissues.
Different parts of a colon are used for the creation of a stoma. Colostomy patients can use the irrigation method. It helps them to predict their next bowel movement and they can live without wearing a pouch. They usually use a cap or a stopper over the stoma instead of the pouching system. This cap can be helpful to absorb any possible mucus and protects stoma, and your clothes.
A urostomy is also known as the ileal conduit. During this surgery, the surgeon attaches the ureters with the one end of the ileum and brings the second end to the abdominal surface to form an opening, stoma. A conduit is formed through the section of the ileum, that’s why a pouching system is a required must.
A normal and healthy stoma appears dark pink and red. It looks damp, bright, and non-ulcerated. You feel no pain over the stoma. With time, it shrinks in size. Mostly, it takes six weeks for a stoma to heal. If you notice something extraordinary you must consult it with a doctor.
Typically, a stoma is submerged indicating that it comes a little out of the skin. This helps in attaching the pouching system. In the case of ileostomy and urostomy stoma maybe two centimeters over the skin while one centimeter in case of colostomy. The height may differ depending on the obesity, shortening of intestines, and tumors.
Stomas that are flat with the skin or more embedded give hard time to the patients for attaching pouching system. In this type of stoma, there are chances of more leakage of feces and urine below or beneath the pouch. If a patient with budded stoma notices any retraction he or she should contact the doctor.
Sometimes a stoma gets prolapsed and a part of the intestine can protrude out. It is an alarming situation. There can be many reasons for a prolapsed stoma, such as:
- Strained abdominal muscles
- Increased pressure between the abdomen
- Parastomal hernia ( a serious condition)
- Surgical errors
The prolapsed stoma can be treated with sugar or a cold compress. Both of the methods lessen the swelling.
Site for the stoma
The stoma can be created in any portion of the abdomen ( all four quadrants). It depends on the type of Ostomy. The location of a stoma is very important as it can prevent many complications and stool output also depends on the location of the stoma.
During the first few days after the surgery, a patient is not allowed to take anything by mouth (N.PO). There is very low stool output and it is very dark hot red. Gradually food and liquids are allowed and the output starts to change. It becomes dark green and then becomes brown and there is also an increase in the output.
As soon as a person starts to eat through the mouth there can be an odor in the stool. It can make you awkward in public places. For this issue, a filter or deodorant is placed inside the pouch.
The output depends on the type of Ostomy and part of the intestine that is involved. For example, Ileostomies outputs are liquid, semisolid feces are formed as a result of ascending or transverse colostomy. And output results of descending and sigmoid colostomy are completely formed solid.
The output of the urostomy differs from other ostomies that produce feces. Urine production should start instantly. There might be blood in the urine for some time after the urostomy. The patient may also notice mucus, it is normal and it will decrease after some time of the surgery.
To prevent the blocking of the ureters stents are placed and brought outside the stoma. These are very flexible, lenient. After some days of the surgery, they are removed by the doctor. Sometimes you may notice urine dripping out of these stents. In this condition, advice from a healthcare provider is needed.
Stoma skin problems
ICD or irritant contact dermatitis is the most common skin issue following the Ostomy. It takes place due to the interaction of bowel contents with the skin. It might be due to pouch leakage or sealing issues.
It almost affects 55% of the patients after the Ostomy. The symptoms of ICD are:
- Loss of epidermal tissues
- Damp area
If it is left untreated it can cause more soreness or discomfort. The skin around the stoma should look normal just like the other skin on the abdomen.
Mucocutaneous separation is another complication. It occurs if the clamps or sutures that hold the stoma to the abdomen get too rigid and if the blood supply to the stoma is disturbed due to any reason. In this condition, the clamps are lost and there is a hollow by the side of the stoma. This space or pocket is filled with alginate and is bandage by using hydrocolloid, then the pouching system is placed.
Some other skin issues are:
- Contraction of the stomal opening is called stoma stenosis
- Stoma becomes very dark or black called stoma necrosis
- Redness and moist skin around the stoma called allergic contact dermatitis
- Enlargement of blood vessels known as peristomal varices
- Inflated hair follicles called folliculitis
- Ulcers nearby the stoma, ulcerative colitis, Crohn’s disease, and arthritis
Things you must know about the pouching system
Ostomy pouching systems are used for the collection of urine or stool. They differ in size and structure. There are some noticeable differences.
Types of the Pouching system
The pouching system used for colostomy or ileostomy can have an open or closed-end. A patient who uses an open-end pouch can drain or empty the pouch without removal of the pouch. And it can be closed after emptying it. While a pouch with closed ends needs to be removed each time you want to empty it. These pouches are odor-resistant. If there is no leakage or there are no fees attached outside the pouch, the odor must not be there.
The main difference between the urostomy pouches is that it has a spout at the end of the pouch. This end is used for draining the urine out. You must keep the spout in the open position when you want to drain the pouch. There is also an antireflux baffle that prevents the backflow of the pouch. You can use a connector along with a spout to increase the storage capacity of the pouch during the night. It will help you to have proper sleep without any disturbance.
Pouching systems are classified as a one-piece barrier or two-piece barrier. The only difference between a one-piece pouching system and a two-piece pouching system is that there is no separation between the skin barrier and the pouch in the case of a one-piece pouching system.
How to empty and change the pouch?
The pouch should be emptied when it is almost one-third filled. If the pouch gets heavy it pulls the pouch downward and there might be a leakage of the bowel contents.
If you notice any leakage you must change your pouch immediately. Otherwise, it can cause peristomal skin issues.
You can wear a pouching system for two to three days if there is no leakage. Don’t confuse yourself between changing the pouch and emptying the pouch.
How to prevent popping of the pouch
Sometimes there may be a lot of gas in the pouch. If the gas is not ventilated at a time the pouch becomes like a balloon. The patient can use a filter within the pouch which helps in preventing gas accumulation and is odor resistant.
Before leaving a hospital a patient must know how to change or empty the pouch, how to observe the stoma, and cut the skin barrier according to the size of their stoma. You should encourage your patients to look at their stoma. You must help them to believe that there is nothing shameful or embarrassing about it.