There are about 120 000 people living with a stoma in the UK, with about 25 000 new stoma operations (ostomies) taking place each year. In 2017, there were about 11000 new colostomies, 9000 new ileostomies and 1660 new ileal conduits created (Lister et al, 2020). The most common underlying conditions resulting in the need for stoma surgery are listed in Box 1.
A stoma, which it is an artificial opening on the abdomen to divert flow of faeces or urine into an external pouch that is located outside of the body, can be temporary or permanent. Colostomy and ileostomy are the most common forms of stoma (Figure 1), but a gastrostomy, jejunostomy, duodenostomy or caecostomy may also be performed. Understanding the type and extent of surgical intervention in each patient is crucial in managing the patient's nursing needs correctly. It is important to recognise that, once a stoma has been formed, the patient (ostomate) will require an appliance that attaches to the abdomen to collect and dispose of the elimination products.
Types of stoma
Colostomy
A colostomy is formed when only part of the large bowel is removed and, according to Lister et al (2020), the most common site for a colostomy is on the sigmoid colon. The colostomy will produce a semi-solid or formed stool and is generally positioned in the left iliac fossa and is flush to the skin. Stomas formed higher up along the colon will produce a slightly more liquid stool. A colostomy tends to be active on average two or three times a day, but this can vary between individuals. Additionally, the faeces that pass through a colostomy are usually more formed than those from an ileostomy, because some of the water is removed as the faeces pass on their way through the bowel. The waste passes out of the colostomy and is collected in an external pouch (colostomy bag). It is important that nurses understand the key functions of the colon in order to support people who have a colostomy.
Urostomy
An ileal conduit is the most common form of urostomy; the colon (colonic conduit) may also be used. There are two basic options for urostomy surgery, often called urinary diversion (American Cancer Society, 2020): incontinent diversion (sometimes called a standard or conventional urostomy) and a continent diversion (also called a continent urostomy or continent urinary reservoir). To make an ileal conduit, a 15–20 cm piece of the lower part of the small intestine (called the ileum) is removed near where it attaches to the large intestine (colon). The rest of the ileum is then reconnected to the large intestine. The ureters are detached from the bladder and attached to the piece of ileum that was removed. The bladder may or may not be removed. One end of the ileum is brought through the front of the abdominal wall to form the stoma and the other end is sewn closed to form a pocket that holds the urine inside the body. This surgery is a lifelong change. The urine output cannot be controlled and the patient will always have to wear a collection pouch.
Ileostomy
Ileostomies are formed when a section of ileum is brought out onto the abdominal wall; the positioning is generally at the terminal end of the ileum on the right iliac fossa, but it can be anywhere along the ileum (Lister et al, 2020). Faeces pass out of the ileostomy and are collected in an external pouch (ileostomy bag). Ileostomies are often formed during rectal cancer surgery to allow the area to rest and heal following the procedure. The waste produced is usually liquid rather than solid.
There are two main types of ileostomy:
Loop ileostomies are usually intended to be temporary and can be reversed during an operation later, while end ileostomies and ileo-anal pouches are usually permanent.
Stoma reversal
Some stomas are described as temporary, which means that there is a possibility that it can be reversed and normal bowel function resumed. Two areas of the bowel are used to form a temporary stoma. The ileum (small-bowel), which results in a loop ileostomy, or the colon (large bowel), which results in a loop colostomy. The function of both is to divert the flow of stool (faeces) away from the newly joined anastomosed section of bowel.
Reversing a loop colostomy is a relatively straightforward process. A cut is made around the stoma to enable the surgeon to access the inside of the abdomen. The upper section of the colon is then reattached to the remaining section of the colon. An end colostomy can also be reversed, but involves making a larger incision so the surgeon can locate and reattach the two sections of colon. It also takes longer to recover from this type of surgery and there is a greater risk of complications. Most people are well enough to leave hospital 3–10 days after having colostomy reversal surgery (NHS website, 2020). It is likely to take some time before bowel movements return to normal. Some people will have constipation or diarrhoea, but this usually improves with time (NHS website, 2020).
Clinical governance
The Association of Stoma Care Nurses UK (ASCN UK) (2016) has issued national clinical guidelines recommending that preoperative counselling and stoma siting should be undertaken by a clinical nurse specialist with appropriate stoma care qualifications. Each organisation will have local arrangements for who should perform this function based on the local governance structure, but training and competency assessment are essential.
Stoma care is a fundamental area of nursing practice that all registered nurses should have the competence to undertake. Due to the increasing demand for good, effective stoma care, there are many courses and conferences focused on improving patient care and enhancing professional knowledge and skills; these are organised by ASCN UK (https://ascnuk.com/default.aspx), and there is also local inhouse training by stoma care nurses.
Many of the core nursing skills in stoma care are carried out by healthcare assistants and carers, and the increasing demand for education in this area should be targeted not only at nurses, but also healthcare assistants and carers.
Nursing considerations
Patient preparation
The role of the nurse specialist should not be underestimated. Once a decision is made that the patient will require a stoma, the individual will be introduced to the stoma nurse specialist, who can provide counselling, as well as information on:
| Preparation and equipment |
| The nurse should ensure the appropriate equipment is available, including: |
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| Procedure |
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An important part of preparing patients for stomas is to ensure the site is appropriate for each individual. Poor siting leads to a stoma that the patient will have difficulty changing and cleaning, in turn increasing the risk of skin problems and other complications.
Once patients have been discharged, they are usually supported within the community by their GP and district nurses, especially in the initial period of adjustment. The nurse should provide education on wearing the appliance, which must not be restricted by clothing or waistlines, and explain that, although the faeces and urine can usually be flushed down the toilet, the bags must not be discarded by flushing. A colostomy or ileostomy pouch should be placed in a bag and then disposed of in the dustbin.
Ileostomies and urostomies usually have features that allow the contents to be drained.
Communication
Individuals with bowel dysfunction problems often feel stigmatised and embarrassed about their problem and may find it difficult to discuss it with others. As a health professional, it is imperative to be empathetic and sensitive to the feelings of these patients, so they feel they can discuss their symptoms freely without feeling judged or embarrassed (Nursing and Midwifery Council, 2018; Royal College of Nursing (RCN), 2020). It is therefore important to use different types of communication to ensure that the individual understands what is being conveyed to them. This includes giving the patient tools to help them describe their symptoms, for example, using the Bristol stool chart to describe their stool (a version can be found on the National Institute for Health and Care Excellence website: http://tinyurl.com/yxtr75dg). There are many ways to communicate with an individual, depending on their needs, ability, and preferences. Use appropriate body language, eye contact and methods of listening that will actively encourage individuals to communicate. It is essential to develop a rapport by using active and empathic listening skills and being non-judgemental (RCN, 2020). Aspects to consider for effective communication include:
Psychological aspects
It is important to recognise that stomas care is always about the patient. Nurses can often concentrate on the effectiveness of the stoma bag—how much stool it can hold and whether the patients can manage changing their stoma bags themselves. It is often forgotten that the patients must live with the stoma bag. Not every ostomate wants the world to know that they have a stoma, and a discreet bag can offer the person a much better quality of life (Payne, 2015).
Society does not routinely or openly discuss bodily functions, especially when it comes to emptying the bowels. These topics remain taboo. Support and psychological welfare can also help improve the person's quality of life and physical health. Being happy and comfortable with a stoma bag can have a positive effect on an ostomate's life. They can exercise, leave the house and socialise with confidence, perhaps even return to the life they had before the formation of the stoma, both in their family life and work (Payne, 2015).
Nurses must recognise that having stoma formation is a major event and patients can become anxious and depressed following the ostomy procedure. Counselling is vital, and this may need to involve mental health specialists. Thus, good preparation of patients in advance of the surgery using visual aids and written information is crucial. Introducing potential patients to those who have already undergone the procedure is a valuable method of preparing patients for the procedure and living with the stoma following the surgery. Video vignettes of patient sharing their experiences have proved effective (Knott and Cox, 2020).
Quality of life can deteriorate for patients following the stoma procedure. The first few weeks post-stoma surgery is the most vital. Patients may have difficulty managing their stoma around their life, eg going out shopping and needing to change the stoma bag without access to adequate facilities. This can contribute to the patient experiencing low mood. Supportive family and friends are essential in helping the patient in this situation.
Stoma bags will also have an impact on the patient's body image, and their intimate relationships may suffer. It is good practice, therefore, to enquire about a patient's personal and social life, and their work situation.
In the first few weeks following the formation of a colostomy or ileostomy, patients may experience sudden urges to defecate. This is known as the ‘phantom rectum’ and can be very distressing. Reassurance and support are helpful.
Physical aspects
Changes in faeces
There may be changes to the amount and consistency of faeces. With ileostomies, faeces are produced about 4 hours after a main meal, whereas with a colostomy, faeces are produced the following morning. Ileostomies are associated with increased output. Often patients have to change their diet to control wind and malodour, which are caused by fizzy drinks and fish respectively. Flatus filters are also available. Leakage of the stoma bag contents can occur and recurrent leakage can cause skin inflammation. This can be distressing for patients and may affect them not only physically but psychologically as well.
Stomas and skin problems
The skin at the site of the stoma can become erythematous and fissured, or the patient can develop an allergic reaction to the materials used in stoma equipment.
A range of seals is available to cover and protect the opening, and it is important that nurses make the patient aware of the options. Similarly, specific hypoallergenic products are available for use in patients with stomas, eg lotions and cleansing wipes.
Stomas and dehydration
Ileostomies usually have a very high output and thus there is a risk of dehydration. Patients need to have a good intake of fluid, which should be about 1 litre above their usual consumption. However, it is prudent to advise patients to avoid fizzy drinks and beer because these may cause flatulence.
Bleeding
It is common for some bleeding to occur from the stoma site following bag changes. Where this has occurred, the patient simply requires reassurance. This type of minor bleed needs to be distinguished from luminal bleeding, which may be a sign of underlying disease, eg a flare-up of inflammatory bowel disease. A rarer cause of bleeding is portal hypertension in patients with liver disease. They may have dilatation of cutaneous veins around the stoma site.
Dietary considerations
After any operation, it can take some time for a person's appetite to return and, after bowel surgery, it also takes a while for the gut to recover from the trauma. In many hospitals, there are protocols for the reintroduction of fluids and foods to try to build up a patient's confidence and to allow the bowel to settle down. To begin with, it is often easier to cope with a light or easily digestible diet that is not too spicy, fatty, highly flavoured or too high in fibre.
If a patient had problems tolerating certain foods before surgery, they may also be particularly anxious about reintroducing a normal diet. If they have lost a lot of weight before and/or immediately following surgery, then it is important to try to regain a healthy weight (Jones, 2016).
Urostomy
There should be no need for any dietary restrictions for patients with a urostomy. However, patients should be encouraged to drink plenty of fluids, to prevent urinary infection.
Colostomy
Again, there should be no need for any dietary restrictions and the patient should be encouraged to eat plenty of fruit and fibre to prevent constipation. However, they may find that too much fibre and fizzy drinks may cause flatus. If flatus is a problem, the patient may choose to limit their intake of fibre and fizzy drinks.
Ileostomy
A normal diet should be encouraged; however, some foods, if not chewed thoroughly, may cause a blockage.
The fact that the colon has been excised or that it is no longer connected to the functioning digestive tract means that patients will lack the absorptive capacity of the colon and they will lose 50-80 mmol of sodium per day. Adding an extra teaspoon of salt to food each day will replace the sodium. Patients should also be encouraged to maintain an adequate fluid intake, but should be discouraged from drinking large quantities of fluid with their meals. Eating a diet high in dietary fibre may increase flatus or contribute to a higher volume fluid output (Fulham, 2008).
Stoma supplies and equipment
A specialist stoma nurse, who usually assesses and manages the patient's stoma care needs before and after an ostomy operation, will help the ostomate choose the most suitable equipment. Once the patient is discharged home, they will need further supplies from a chemist or from a stoma supply company. People living in England can get these products on prescription from their GP and, if they are aged under 60 years, they will need to sign a form to get free prescriptions. All prescriptions are free for anyone living in Scotland, Wales and Northern Ireland (Joint Formulary Committee, 2020).
White (2018) highlighted the benefits of having a list of different products made available as a resource for nurses caring for ostomates. Guidelines for GPs regarding the average frequency of product usage help prevent overordering and waste, but ordering needs to be overseen by a specialist nurse with experience of stoma care nursing. There is no ‘one size fits all’ either, because the individual attributes of each patient need to be taken into consideration, such as type of stoma, its position and the patient's ability to self-care. Estimating each patient's average use of different products, while never exact, can prepare the GP for prescription requests from the nurse. It can also alert staff to possible overuse of products. The patient's needs should be judged on merit and the effect of the stoma on the patient's quality of life must be taken into consideration when recommending products. Table 2 shows the average monthly use of stoma products for a patient with a colostomy, an ileostomy or a urostomy. Additional products that can improve daily living for a patient with a stoma include:
| Appliance | Usual monthly quantity | Prescription directions | Notes |
|---|---|---|---|
| Colostomy bags (one-piece systems) | 30–90 bags |
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Bags are not drainable. Usual use: 1–3 bags per day. Flushable bags only to be used on advice of bowel/stoma care nurse |
| Colostomy bags (two-piece systems) | 30–90 bags + 15 flanges |
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The flange (base plate for 2-piece systems) is not usually changed at every bag change. Items are ordered separately |
| Irrigation | 1 kit |
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Irrigation is a method of managing a colostomy but should only be used under the direct supervision of a stoma care nurse |
| Irrigation sleeves | 30 |
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Self-adhesive disposable sleeves |
| Stoma caps | 30 |
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This may be in addition to original stoma bag |
| Ileostomy bags (one-piece systems) | 15–30 bags |
|
Bags are drainable |
| Ileostomy bags (two-piece systems) | 15–30 bags + 15 flanges |
|
The flange (baseplate for 2-piece systems) is not usually changed at every bag change. Items are ordered separately |
| Urostomy bags (one-piece systems) | 15–30 bags |
|
Bags are drainable |
| Urostomy bags (two-piece systems) | 15–30 bags + 15 flanges |
|
The flange (baseplate for 2-piece systems) is not usually changed at every bag change. Items are ordered separately |
| Night drainage bags for urostomy patients | 4 bags (1 box of 10 bags every 2–3 months) |
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Bags are drainable |
Conclusion
Having stoma surgery is life changing and can have serious psychological consequences for patients, such as problems with body image. Planned, individualised preoperative preparation, postoperative care and teaching, will help to minimise complications and enable patients to cope and achieve self-care. It also important to explain to patients that, with preparation and appropriate accessories, they should be able to do most of the activities they did before surgery, such as swimming.
Understanding the problems that patients can face and having good knowledge of the range of available stoma appliances and accessory products will enable nurses to offer patients acceptable solutions to stoma-related physical consequences of living with a stoma and help them to maintain their quality of life, returning to work and social activities, and, in some cases, avoid further surgery. Continued support of the patient and/or carer and long-term follow-up will help ensure that the patient continues to have a good quality of life.