Raising sensitive issues
It may fall to an LTC nurse to explain how a stoma should be managed.
If there is a key word to describe the challenge of ostomy management, “sensitivity” seems like an appropriate choice. It has dual connotations: First, it concerns an intrusive surgery that leaves patients emotionally vulnerable and therefore in need of extra compassion; and second, treating related complications requires protecting delicate skin from abrasion.
The National Alliance of Wound Care and Ostomy reports that approximately 120,000 ostomy surgeries are done in the United States each year and that complications following them is “a significant problem” for many patients. Up to 71% of patients with an ileostomy experience complications, as do 43% with a colostomy. Many of these patients are residents in long-term care facilities.
While the number of post-op ostomy residents pales in comparison to those with pressure ulcers, they still deserve caregivers' rapt attention, clinical specialists say. NAWCO reports that post-op residents “will often report a loss of confidence, independence and dignity, as well as fears of rejection and ridicule,” which means that caregivers need to show special consideration when dealing with these residents.
Nancy Morgan, RN, founding partner of the Wound Care Education Institute, says that while ostomy management practices have evolved slowly over the past decades, education for patients needs to become a higher priority.
“Approximately 80 percent of ostomy patients do not seek help with peristomal skin problems — one of these reasons is access to care and the other is patient education,” says Morgan, who has more than 20 years' experience and is certified in wound care, ostomy and diabetic wounds. “With quick admission and discharge policies in hospitals, the nursing staff does not have enough time to adequately educate patients on proper care and when to seek help.”
Estimates say that between 35% and 57% of ostomy patients sustain some type of peristomal skin problems due to an incorrect appliance, Morgan says.
“The biggest challenge is getting a good seal,” she says. “If the appliance fits correctly, then the majority of all problems are taken care of before they begin. Best practice shows that patient follow-up in the first couple of months after surgery can alleviate complications.”
Among the most significant developments in ostomy management are surgical procedures that alleviate permanent stomas and facilitate quicker post-op recovery, says Janice C. Colwell, RN. She is an advanced practice nurse in wound and ostomy care for the University of Chicago Medicine and a past president of the Wound Ostomy and Continence Nurses Society.
Disease management has progressed to the point where procedures that once created a permanent stoma may result in a temporary stoma, Colwell says.
“For instance, with colorectal cancer treatments, chemotherapy and radiation can shrink the tumor significantly, resulting in the need for a less aggressive bowel resection,” she says. “Because of advances, surgeons can now remove a section of the bowel, reconnect it and divert the bowel temporarily while the anastomosis heals. What this means is the patient will have a temporary stoma for three to six months where in the past, the same disease would have been treated with a permanent colostomy.”
New laparoscopic surgical techniques are less intrusive, allowing patients to recover faster, Colwell says. The new surgery involves several small incisions made on the abdomen. Then a scope, camera and tools are inserted to enable the surgery. This technique has many positive outcomes, she says, including less pain, early ambulation, early diet advancement and shorter hospital stays.
“However, since the hospital stay can be quite short — as few as three days — teaching the patient with an ostomy how to manage the stoma in this short time frame can be a challenge,” Colwell says.
NAWCO's research shows that “successful adjustment to a colostomy and improved quality of life is most likely to occur if instruction in self-care and appropriate psychological support is given by a specialized stoma/ostomy clinician.” In response, the group is offering the first multi-specialty Ostomy Management Specialist certification in the United States.
The OMS is NAWCO's fourth certification program, designed for specialized clinicians dedicated to treating and preventing ostomy and stoma complications. The new certification “will greatly benefit our thousands of WCCs and other certificants who work with ostomy patients, or who are considering ostomy as a career direction,” an association statement says.
The Wound Care Education Institute shined a spotlight on ostomy care in the Ostomy Buzz segment of its Wild on Wounds Conference held in mid-September. As the clinical instructor of the session, Morgan covers new ostomy care products (including indications and contraindications for appropriate use), new guidelines, resources, tools and clinical developments that have impacted the ostomy care field over the past year.
Protecting the skin
In designing new ostomy products, manufacturers have focused on the patient's wants, needs and concerns. Skin barriers have become more durable and flexible, resulting in a better fit around the stoma. Pouches are constructed so they are odor-free. This eliminates the need to constantly clean the pouches, and relieves anxiety over odor.
ConvaTec has designed a product that self-molds around the stoma, “where not long ago the only option was cutting to fit and that can be difficult for some patients who have limited mobility, arthritis or poor vision,” Morgan says.
The Sensura Mio by Coloplast has been designed solely based upon clinician and ostomy patient input. The skin barrier is an elastic adhesive that moves and conforms to the patient's body contours, resulting in a snug fit and eliminating the need for extra accessories or convexity. The gray-silver color of the pouch is designed to be less noticeable through clothing in order to maintain patient dignity.
To address the everyday challenge of maintaining intact skin for pouch adherence, 3M has developed the Cavilion No Sting Barrier Film, which features a blend of two polymers. The additional polymer allows the film to flex with the skin and maintain a continuous, protective coating.
More than 70 pieces of clinical evidence support the efficacy and cost-effectiveness of Cavilion, 3M officials say.
Because odor is the chief concern of ostomy patients, manufacturers are responding by making all pouches odor-proof, Colwell says. They are also producing pouches in different shapes and sizes as a solution to the frustrations with the old “one-size-fits-all” approach.
“The advantage of having many options is that the pouches and adhesives can be matched to the patient with the following considerations: the size and shape of the stoma, the contours of the abdominal skin, the type of stoma output as well as patient preferences,” Colwell says. “Matching the pouch to the patient's characteristics assures a good fit, preventing leakage, odor, and gives the patient a better, more active life.”
Going forward, Colwell expects to see pouching systems that can be custom fit, with adhesive seals that can be adjusted by the wearer or caregiver to match the stoma size, shape and peristomal skin.
“Additionally, someone in the ostomy manufacturing field will find a way to deal with gas release from the pouch — today's systems have limited success,” she says.
Future design features also may include pouch materials that feature cloth-like coverings that are soft against the patient skin and prevent rustling of the pouch under the clothes, Colwell says.
“Other innovations I expect to see include pouch closures that will allow easy opening and closing for aged hands and integrated pouch films that provide deodorization of the stoma effluent to decrease odor upon emptying,” she says.
The Wound and Ostomy Care Nurses Society and Wound Care Education Institute recommend the following downloadable apps (Apple and Android) for useful clinical information on wound care and ostomy:
WOCN Evidence-Based Wound Care Guidelines and Fecal Ostomy Best Practice App: Provides up-to-date recommendations for patients with pressure ulcers, fecal ostomies, lower extremity arterial disease (LEAD), lower extremity neuropathic disease (LEND) and lower extremity venous disease (LEVD).
WCEI Wound Central App: Includes step-by-step instructional videos, anatomical reference guides, keyword search, wound care image library and instant information on virtually every type of wound.