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Care of patients with a stoma


NS688 Burch J (2013) Care of patients with a stoma.
Nursing Standard. 27, 32, 49-56. Date of submission: November 5 2012; date of acceptance: February 1 2013.

Abstract
Several diseases and operations may necessitate the formation of a
stoma. Patients may be concerned about the effect of the stoma on their
ability to carry out activities of daily living, as well as quality of life. Nurses
who may be involved in the care of patients with a stoma should have an
understanding of the reasons for stoma formation, and the types of stoma
and appliances available, to educate and support patients, and allay any
concerns. Issues related to diet, sexual relationships and self-image are
also discussed briefly.

Author
Jennie Burch
Enhanced recovery nurse, St Marks Hospital, Harrow.
Correspondence to: jburch1@nhs.net

Keywords
Continence, gastrointestinal system and disorders, stoma formation,
surgery, urinary system

Review
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Online
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search using the keywords above.

Aims and intended learning outcomes


This article aims to increase readers
knowledge of caring for patients with a stoma.
After reading this article and completing the
time out activities you should be able to:
Understand

the anatomy and physiology
of the gastrointestinal (GI) tract and
urinary system.

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Explain

the diseases and operations that may
result in formation of a stoma.
Identify

the three main types of stoma,
the common appliances used and their
stomal outputs.
Allay

common patient concerns and
anxieties about the need for a stoma and
offer lifestyle advice.

Introduction
There are approximately 100,000 people in
the UK with a stoma, also termed an ostomy
(Black 2009). There are three main types of
stoma: colostomy, ileostomy and urostomy,
also known as an ileal conduit. The colostomy
is formed from the large bowel or colon and
the ileostomy is formed using the small bowel
(ileum) to provide an alternative route for the
passage and excretion of faeces. The urostomy
allows the passage and excretion of urine,
and is formed from a small segment of the
ileum. These types of stoma will be discussed
in detail later in the article. Before stoma
formation surgery, nurses should be available
to answer any questions the patient may have
about the procedure and allay concerns. It is
important that patients understand why they
need to undergo surgery and are given support
to help them accept the changes that stoma
formation will have on their bodies and lives.
Complete time out activity 1

Anatomy and physiology


Gastrointestinal tract

The GI tract is the passage that runs from the


mouth to the anus, where nutrients and energy
from food and fluids are used, and waste is
excreted in faeces and urine. Food and fluid
in the mouth are broken down by the action
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of the teeth and saliva, and then pass to the
stomach for further digestion by enzymes.
On leaving the stomach, chyme partially
digested stomach contents passes into the
small bowel, which consists of the duodenum,
jejunum and ileum. During passage through
the small bowel, more digestive enzymes are
added to the bowel contents, and nutrients and
vast volumes of fluid are absorbed (Tortora
and Derrickson 2007). Approximately
1,500mL of loose faeces leave the ileum, at
the terminal ileum, and pass into the colon
(McGrath 2005). Anecdotally most patients
with an ileostomy will pass less than one litre
of loose faeces per day.
Faeces travel along the colon through the
caecum, ascending colon, transverse colon,
descending colon, sigmoid colon, and rectum
and anal canal before leaving the body via the
anus. During this period in the colon, further
fluid is absorbed and loose stool becomes
formed stool. In addition, the colon absorbs
sodium and produces flatus.

Urinary system

The urinary system consists of two kidneys, with


a ureter attaching each kidney to the bladder and
a single urethra to enable the passage of urine
from the body (McGrath 2005). Urine is formed
in the kidneys and passes into the bladder for
storage before being excreted.
Complete time out activity 2

1 Using an
appropriate textbook,
revise the anatomy
and physiology of
the gastrointestinal
(GI) tract and urinary
system. Draw and label a
diagram of the GI tract
and compare it with the
textbook version.
2 Reflect on the
diseases of the lower GI
tract and urinary system
that may necessitate
formation of a stoma.
3 Explore the
different types of
surgery that result
in the formation of a
stoma and what parts
of the body are resected
during each operation.

Diseases that may necessitate


stoma formation
There are several diseases that can result in
stoma formation, however only the most
common of these will be discussed. All
operations will be explained in more detail in
a subsequent section, but a brief explanation is
provided to assist the reader in understanding
how diseases can result in stoma formation.
Rectal cancer frequently necessitates
formation of a stoma, and in some cases an
abdominoperineal resection of the rectum
and formation of a permanent end colostomy
is required. This involves the removal of
the rectum and anus and formation of a
colostomy. This type of surgery may be
indicated if the cancer is low in the rectum.
A rectal cancer might, however, be removable
via an anterior resection with or without a
temporary loop ileostomy formation. This
operation involves removal of part of the
rectum and joining of the resected ends
(Windsor and Conn 2008). Cancer of the

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colon may result in a sigmoid colectomy


(removal of the sigmoid colon), left
hemicolectomy (removal of the left side of the
colon) or right hemicolectomy (removal of the
right side of the colon), but these operations
will rarely necessitate formation of a stoma.
Inflammatory bowel disease involves two
main disease processes: ulcerative colitis and
Crohns disease.
Ulcerative colitis is a disease that affects
the colon, causing ulcers and rectal bleeding
(Hart 2011). The disease can be debilitating
and if medical treatment fails, surgery may be
necessary. For people with ulcerative colitis,
the removal of the colon and rectum may be
required and this can result in a permanent
end ileostomy termed a panproctocolectomy
and ileostomy. This surgery involves removal
of the whole colon, rectum and anus, with
formation of an ileostomy. Alternatively, a
sphincter-saving operation preserving the
anal sphincters to allow passage of faeces or
pouch procedure removal of the entire colon
and rectum, and joining of the anal canal to a
pouch formed from the small bowel may be
undertaken, requiring a temporary ileostomy
only, although multiple operations will be
needed (Perry-Woodford 2008).
Crohns disease can also result in the
formation of a stoma. As Crohns disease can
affect any part of the GI tract, from the mouth
to the anus (Hart 2011), it is important that the
surgeon considers carefully the operation to be
undertaken to preserve as much of the bowel
as possible and prevent the patient ending up
with a shortened bowel. However, people with
peri-anal Crohns disease that has fistulated,
may require the fistula to be defunctioned by
the formation of a loop colostomy. A fistula is
a small tract that passes from the rectum to the
vagina, buttock or anal area. Defunctioning
means that a loop colostomy is used to divert
faeces from the rectum and away from the
fistula tract that goes to the peri-anal skin,
enabling healing to occur. The colostomy is
often used in conjunction with surgical repair
(Clark 2011).
Diverticular disease is the presence of
small pockets in the colon called diverticula,
which are increasingly present in older people;
although the reason for this is unclear, it may
include a poor diet resulting in constipation
(Black and Hyde 2005). For most people,
diverticula cause no symptoms, but can
cause abdominal pain and changes to bowel
motion. However, if a diverticulum perforates,
bowel contents can leak into the abdominal

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cavity causing peritonitis, which can be life


threatening. In this situation, emergency
surgery is required, most commonly a
Hartmanns procedure and formation of a
temporary end colostomy. The Hartmanns
procedure involves the removal of the sigmoid
colon and some of the descending colon. Since
it is unsafe to rejoin the bowel in the presence
of infection, a colostomy is formed. The bowel
ends can be rejoined at a later date (Windsor
and Conn 2008).
The most common disease requiring the
formation of a urostomy is cancer of the bladder.
This type of cancer may necessitate removal of
the bladder. Other less common diseases that
may result in urostomy formation include spina
bifida and interstitial cystitis (Burch 2008).
Complete time out activity 3

Surgery
Anecdotally, stomas have been formed for
many years, with minimal changes in surgery
in the past 30 years. The major changes made
historically were the development of the
spouted ileostomy by Bryan Brooke in the
1950s (Brooke 1952). This led to a marked
improvement in peristomal skin (skin around
the stoma) by keeping the corrosive ileostomy
output away from the peristomal skin (Taylor
2012). In the 1960s the Kocks pouch was
invented, which is a continent stoma that is
joined inside the abdominal wall and has a
small opening on the abdomen that is emptied
using a special catheter (Kock 1969), and in
the 1970s Parks and Nicholls developed the
ileoanal pouch, which is the formation of a new
rectum using the small bowel (Parks et al 1980).
There are a variety of operations that can be
undertaken to form a stoma. These are listed
in Box 1.
As discussed, abdominoperineal resection
of the rectum involves removal of the anus,
anal sphincters, anal canal and rectum, with
the formation of a permanent end colostomy in
the sigmoid or descending colon. A Hartmanns
procedure is often performed in the emergency
situation, involving removal of part of the
rectum and sigmoid colon, with a temporary
end colostomy being formed in the descending
colon (Windsor and Conn 2008). During this
operation, the rectal stump is either over-sewn
and left inside the abdominal cavity or is
brought out as a mucous fistula. A mucous
fistula will appear as a small stoma, but will
not pass flatus or faeces, only mucus. A mucous
fistula can be useful for several reasons, for

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example if there is a build up of mucus in the


rectum, this can be discharged via the mucous
fistula rather than the anus. Anecdotally, when
the colon is rejoined it is simpler to find the
rectal stump if it is stitched under the
abdominal wall rather than left inside the
abdominal cavity.
An anterior resection is the removal of
part of the rectum and sigmoid colon, with
an anastomosis. In certain situations, this
operation can be extended deeper into
the rectum, which is a technically more
difficult operation to perform, involving
defunctioning of the anastomosis with a
temporary loop ileostomy. This means that
the join in the bowel is defunctioned to allow
the anastomosis to heal; if a small leak in the
anastomosis were to occur, the risks to the
patient are vastly reduced and life-threatening
peritonitis is prevented. Sometimes the surgeon
may resect the fatty tissue around the rectum,
which contains the lymph nodes and blood
vessels, to reduce the risk of cancer spreading.
This procedure is termed an anterior resection
with a total mesorectal excision and temporary
loop ileostomy (Stewart and Dietz 2007).
A total colectomy is the removal of the
colon, leaving only the ileum and rectum.
The term colectomy, subtotal colectomy and
total colectomy are often interchanged and
although there are differences between the
procedures, they generally include removal
of most or all of the colon. The two ends of
the bowel can be joined in a procedure known
as an ileorectal anastomosis. Alternatively,
the end of the small bowel can be brought
out as an end ileostomy and the rectum either
over-sewn and left in the abdomen or brought
out to form a mucous fistula.
Another operation that can result in
a permanent end ileostomy is a
panproctocolectomy. This is the removal
of the anus, anal sphincters, anal canal,
rectum and colon.

BOX 1
Operations that result in stoma formation
Abdominoperineal resection of the rectum and permanent end colostomy.
Hartmanns procedure with temporary end colostomy.
Anterior resection with or without a total mesorectal excision and
temporary loop ileostomy.
Total colectomy and end ileostomy.
Panproctocolectomy and permanent end ileostomy.
Ileopouch anal anastomosis and temporary loop ileostomy.
Kocks pouch.
Cystectomy and urostomy.

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4 Describe a
colostomy, ileostomy
and urostomy, the
appliances used and
the outputs from each
stoma.

An alternative to a permanent end ileostomy


is ileoanal pouch formation (Perrin 2012). This
has many terms including pouch, J pouch and
ileopouch anal anastomosis. This operation
involves the removal of the rectum and colon,
but the anus, anal sphincters and anal canal
are preserved. The ileum is then used to form
a pouch or new rectum and anastomosed
to the anal canal. The new pouch is usually
defunctioned with a loop ileostomy to allow
healing to occur.
The pouch operation can be performed
in one, two or three stages. A one-stage
operation is described above and does not
require a temporary ileostomy, but is rarely
performed. A two-stage pouch operation
is performed on well patients and involves
removal of the colon and rectum, and
formation of a pouch and loop ileostomy.
The ileostomy is reversed in a subsequent
operation. A three-stage pouch procedure
initially involves removal of the colon and
formation of an end ileostomy performed on
unwell patients with ulcerative colitis. The
second operation involves the removal of the
rectum. The end ileostomy is separated from
the abdominal wall and used to form the
ileal pouch and a new loop ileostomy is also
formed. The third and final stage is closure of
the stoma (Perry-Woodford 2008).
A Kocks pouch is rarely performed and is
an alternative to a permanent ileostomy or
ileoanal pouch. A Kocks pouch is a continent
stoma formed after removal of the anus,
rectum and colon. A small bowel pouch is
formed and attached inside the abdomen.
The Kocks pouch is made continent by the
formation of a small valve, just below the
abdominal surface, so that an ileostomy
appliance is not necessary (Perry-Woodford
2008). Faeces are evacuated from the Kocks
pouch through the use of a medina catheter,
which is inserted through the small opening
on the abdominal wall. This is a specialised
catheter that is more rigid and with a larger
lumen than general urinary catheters. Faecal
evacuation needs to be performed around
four to six times daily.
A urostomy is formed most commonly from a
small segment of the ileum and is termed an ileal
conduit. It is also possible, but less common,
to form a urostomy from the colon, termed a
colonic conduit. When a urostomy is formed the
bladder is removed (cystectomy) and the ureters
are attached to the end of the ileal segment
one bowel end is over-sewn to prevent urine
leaking into the abdominal cavity. The other

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end of the segment is formed into the urostomy


(Fillingham 2008).
Complete time out activity 4

Types of stoma
A stoma is the exteriorised bowel used to
divert the passage of faeces or urine to the
abdominal surface to be collected in a stoma
appliance. Stoma is the Greek word for mouth
or opening (McCahon 1999). A temporary
stoma may be formed for a short period of
time, often three to nine months. A temporary
stoma may be used to allow an anastomosis to
heal for example. Alternatively, a permanent
stoma can be formed if the anal sphincters
will be damaged or require removal during
surgery. Furthermore, a stoma can be an end
stoma, which can be temporary or permanent.
An end stoma is formed when one end of the
bowel is passed through the abdominal wall.
In addition, a loop of bowel can be formed
into a stoma and this is usually temporary
and reversed in a subsequent operation. The
stoma is red in colour, wet and warm to touch.
An end stoma is usually round in shape and a
loop stoma may be egg shaped. As mentioned,
there are three main types of stoma: colostomy,
ileostomy and urostomy.
To form a stoma, an incision is made on the
abdomen through all layers of the abdominal
wall. The colon or ileum is brought through
this hole and stitched onto the abdominal wall
with stitches that dissolve about six to eight
weeks after surgery. When first formed, the
stoma is oedematous and the swelling takes
about six to eight weeks to reduce.

Colostomy

A colostomy is formed from the colon,


usually the descending or sigmoid colon.
The most common position for a colostomy
to be formed is in the left iliac fossa (lower left
abdomen, below the umbilicus). A colostomy
is usually 30-35mm in size and minimally
raised above the abdominal wall by around
5mm. The output from the colostomy is soft,
formed faeces and flatus. This will pass from
the colostomy into a closed appliance (Burch
2008). Most people with a colostomy will
usually change their appliance between three
times a day and three times a week; most
frequently once daily. Other methods to care
for a colostomy include continence enhancing
products or colostomy irrigation. Colostomy
irrigation should not however be confused
with colonic irrigation.

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Colostomy irrigation is generally


performed daily and involves the
instillation of water into the colon via the
colostomy using specialist equipment,
including a water container, tubing, cone and
plastic sleeve. The plastic sleeve is attached
around the colostomy in a similar fashion to
a stoma appliance. Warm tap water is placed
into the water container and run through the
tubing. The person with a colostomy then sits
on the toilet, with the sleeve hanging between
their legs into the toilet; the water is then run
into the colostomy via the cone, which has
been gently inserted into the colostomy. The
water passes into the colon and as it leaves the
colostomy into the plastic sleeve, faeces and
flatus are also evacuated. Once the procedure
is completed a small stoma cap is worn
enabling the individual to be free from faeces
and flatus until the next irrigation session
(Readding 2006).

Ileostomy

An ileostomy is formed from the ileum, most


commonly the terminal ileum (Figure 1). The
most common position for an ileostomy is the
right iliac fossa. An ileostomy is often about
30mm in diameter and is formed to have a
small, 25mm spout. This spout keeps the loose
faeces and flatus away from the peristomal
skin. The ileostomy output is collected in a
drainable bag with a Velcro-type fastening.
Faeces are emptied on average four to six times
daily and the appliance is usually changed on a
daily or alternate daily basis.

Urostomy

A urostomy is generally formed from a


segment of ileum. The urostomy is in the
same position and has the same appearance
as an ileostomy. The output, however, is urine
with small amounts of mucus. Urine will pass
into a drainable appliance with a tap or bung
fastening. Urine is passed continually. The
urostomy appliance is emptied around four
to six times daily and replaced on a daily or
alternate daily basis. Overnight, an additional
night drainage bag can be attached to the
bottom of the stoma bag to increase urine
storage capacity.

and any changes to the body, and to educate the


patient about practical care of the stoma.
The nurse will also mark or site the position on
the abdomen where the stoma will be formed.
A stoma site needs to fulfil a variety of criteria,
including location on a flat area of skin that is
visible to aid the appliance change routine.
Pre-operative training helps to reduce
post-operative training time required.
Pre-operative siting may also help to
prevent post-operative complications such as
appliance leakage.
After the operation, the stoma specialist
nurse needs to provide practical stoma
care education to the patient. This includes
how to perform an appliance change, and
understanding what is normal in relation
to the stoma, stomal output and peristomal
skin. Healthy peristomal skin should have the
appearance of normal skin, with absence of
any visible skin changes (Herlufsen et al 2006).
Furthermore, there needs to be a discussion
about diet, exercise, work and sexual
relationships. Following discharge home,
the stoma specialist nurse will be available to
provide advice and support for the duration
that the person has the stoma, which may be
life-long. Complications can occur at any time
following stoma formation, therefore yearly
review by the stoma specialist nurse may be
useful. Follow up by the stoma specialist nurse
can be via telephone call, clinic or home visits.

Appliances

There are three main types of stoma appliance.


The colostomy bag is closed, the ileostomy
appliance is drainable with a Velcro-type
fastening and the urostomy appliance is
drainable and has a bung or tap fastening.

FIGURE 1
End ileostomy

The stoma specialist nurse is pivotal in the


care of patients with a stoma. The nurse sees
the patient before surgery to explain what will
happen during the procedure, about the stoma

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alamy

Role of the stoma specialist nurse

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There are two main parts to the appliance:
the bag part, which is made of plastic and
is usually covered in a cloth-type fabric to
aid patient comfort. The plastic part of the
appliance contains the stomal output and any
smell associated with the stoma. The other part
of the appliance is the adhesive section, which
adheres to the peristomal skin. This section has
a variety of terms including flange, face plate
and base plate. These three types of appliance
are available as one or two-piece appliances. A
one-piece appliance is where the bag and flange
are joined and are replaced as a single unit. A
two-piece appliance has the bag and flange
parts as separate sections, which are joined
together with a clicking plastic ring or adhesive,
depending on the type of appliance.
For most people with a stoma, either a one
or a two-piece appliance will work equally
well and personal choice will generally govern
decision making. However, a two-piece
appliance can be useful for a colostomy that
functions several times daily. The flange can be
left in situ, preventing trauma to peristomal
skin, known as skin stripping which results
from frequent removal of the flange.
Alternatively, a one-piece appliance might be
simpler for people who prefer to change their
appliance completely at one time.
Changing the stoma appliance
The basics of a stoma appliance change are
to collect all the necessary equipment. This
includes a clean appliance, cleaning cloths,
warm water and a rubbish bag. It might also be
necessary to use a stoma measuring guide,
a pen, pair of scissors and any stoma
accessories that are used. The basic appliance
change procedure is detailed in Box 2.

Diet

There are many issues that need to be


discussed with the patient who has a stoma,
including diet. Patients often worry about
the food they can eat and what they should

BOX 2
Appliance change procedure
All necessary equipment is collected.
The appliance is carefully removed and disposed of in the rubbish bag.
The peristomal skin is gently, but thoroughly, cleaned and dried.
The stoma is measured and the aperture in the flange is cut, if necessary.
The aperture or hole is ideally 1-2mm larger than the actual stoma and the
same shape.
The backing paper is removed from the flange and the flange is adhered to the
peristomal skin. If a two-piece appliance is used the bag should be joined.
The appliance is held onto the abdominal skin for 30-60 seconds to help the
adhesion process.

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avoid (Cronin 2012). Advice focuses on


patients as individuals, and therefore there
are no strict rules regarding diet; often it is
sensible to try a food and see how the patient
is affected. However, some general advice is
necessary. It is sensible for all patients with
a newly formed stoma to be careful of their
diet in the first few weeks. This is because the
bowel will be swollen and foods that would
normally be tolerated may not pass readily
through the stoma. Therefore, patients with
a recently formed stoma should be advised to
chew their food carefully before swallowing to
prevent blockages. Patients also need to drink
adequate fluids, ideally 1,500mL or more
daily (Pearson 2008).
Patients with a colostomy can generally eat
and drink as they wish, as little of the GI tract
has been affected, except for the exit being
re-routed from the anus to the abdomen.
To prevent constipation adequate fibre, fluids
and mobility are required.
Patients with an ileostomy will pass
loose stool and there is an increased risk
of dehydration as the role of the colon is to
absorb water and sodium. Approximately
1,500-2,000mL of oral fluid are generally
necessary each day and salt may need to be
added to the diet; however many UK diets are
high in processed foods and high in salt so this
is not always necessary. Many patients with
an ileostomy find high-fibre foods are not well
tolerated and choose to reduce or exclude them
from their diet (Pearson 2008).
People with a urostomy need to take
adequate volumes of fluid of 1,500-2,000mL
daily (Pearson 2008). There is anecdotal
evidence that a daily glass of cranberry juice is
also beneficial in preventing urine infections.
Complete time out activity 5

Psychosocial issues

Adapting to life with a stoma can be difficult


for some individuals. Anecdotally, patients in
the post-operative period concentrate on the
practical aspects of learning how to care for
their stoma, with a focus on appliance change
technique. However, once at home individuals
need to adapt the care that they have learned
to fit in with their lifestyles and daily activities.
During this time, other psychological issues
may arise. People with a newly formed
stoma may question how they can live with
the stoma, whether they can still maintain
relationships with their partners, whether
they can continue to work and what to do
if the stoma bag leaks. Advice from a stoma

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Most people with a stoma wait several


weeks or longer before driving, resuming
sexual relations and returning to work.
Before driving, time should be allowed
to regain strength. Advice should also be
sought from the persons insurance company,
as some companies have a six-week rule
banning driving after surgery. People should
avoid going to the gym for two to three
months following surgery. The use of a
hernia support belt might be sensible when
undertaking strenuous activities. Parastomal
herniation occurs in more than half of
people with a stoma and there is evidence
that wearing a support belt in conjunction
with abdominal exercises in the first year
or longer after surgery can prevent this
(Thompson and Trainor 2005). Another
accessory that people with a stoma might find
useful is a stoma shield. This is a small, hard,
plastic dome worn with a thin elastic belt
on top of the stoma appliance and under the
clothes to protect the stoma. This is useful for
contact sports to prevent inadvertent damage
to the stoma.
There are a variety of complications that
may affect people with a stoma (Boyles 2010).
In general, it is advisable to seek the assistance
of the stoma specialist nurse for assessment
and treatment. It is also recommended that
people with a stoma are reviewed on an annual
basis to assess that the stoma and peristomal
skin are healthy. It is also important to ensure
that products prescribed for the patient are
used appropriately and meet the persons
needs. A commonly reported problem is an
appliance leak (Porrett et al 2011), which can

FIGURE 2
Sore peristomal skin

mediscan

specialist nurse or support group can


be invaluable to allay patient concerns (Ferrer
et al 2010).
Changes in body image as a result of stoma
formation can be difficult to accept at any age.
Research shows that there are many factors
that affect quality of life and coping following
formation of a stoma (Nichols and Riemer
2011). Learning to live with the newly-formed
stoma often involves making changes to the
individuals lifestyle. A little extra time in the day
is needed to undertake the appliance change, for
example. It is important to remind the person
that the stoma was formed to improve his or her
quality of life, for example to remove a cancer.
Having a sexual relationship is also possible
for most people with a stoma. However,
males with a urostomy will be unable to
have a natural erection. Women undergoing
abdominoperineal resection of the rectum
might find that the position of their vagina
alters slightly after the rectum is removed,
which may alter sensation during sexual
intercourse. Both males and females with a
stoma have the potential to have children, but
because of the changes that occur as a result
of having surgery, fertility might be affected.
Fertility is reduced in females with an ileoanal
pouch, probably as a result of adhesions
that form inside the abdomen as a result of
abdominal surgery (Perry-Woodford and
McLaughlin 2011).
It should also be noted that while reasonably
rare, there are children with a stoma. Children
may be born with an imperforate anus or
inflammatory bowel disease, for example. An
imperforate anus is rare, but the baby is born
without an anus and requires the formation of
a stoma to pass faeces.
People with a stoma should be able to
undertake any type of occupation, activity,
hobby or sport. However, caution should
be exercised where incisions have been
made in the abdominal wall, even if
laparoscopic (keyhole) surgery was
performed. Any incision may result in the
formation of an incisional or parastomal
hernia. An incisional hernia might occur
through one of the incision sites and a
parastomal hernia may cause swelling
directly around the stoma, which might result
in poor appliance adhesion. It is advised that
only light activities such as walking should be
undertaken in the immediate post-operative
period and strenuous activities avoided until
abdominal healing occurs. It is advisable to
increase activity gradually as tolerated.

5 Reflect on the
patient information
available in your work
area related to stoma
care. Suggest how you
can improve this, making
sure that all patients
needs are met?
april 10 :: vol 27 no 32 :: 2013 55

05/04/2013 12:15

Learning zone continence

6 Now that you have


completed the article,
you might like to write
a practice profile.
Guidelines to help you
are on page 60.

result in sore peristomal skin (Williams et


al 2010). Sore skin can also result from skin
stripping, but an allergy to an appliance is
rare. It can present as erythema (red skin),
skin erosion, weeping, bleeding and ulceration
(Figure 2) (Lyon and Smith 2010), and needs
to be assessed accurately to instigate treatment
(Jemec et al 2011).
Simple adjustments to care may be helpful,
such as reviewing the appliance change
technique. Alternatively, a stoma accessory,
such as adhesive paste or seals, can aid
appliance adhesion. An adhesive remover can
help remove the appliance from sore or fragile
skin. Furthermore, a skin barrier can be used
to protect peristomal skin from the stomal

output to reduce the risk of sore skin developing


(Rudoni 2011, Thompson et al 2011).

Conclusion
Stoma formation can be life-changing for
individuals, but with appropriate patient
education and support, good quality of life is
achievable. Individuals may have to adjust the
way they carry out daily activities, but there
are many strategies and appliances that can be
used to make this easier. Individuals self-image
may also be affected, and patients will need to
be given appropriate support to minimise the
psychosocial effects of living with a stoma NS
Complete time out activity 6

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