Stoma care in any patient should be adapted to the individual's needs. However, patients aged over 65 years are at increased risk of reduced mental wellbeing and decreased independence (National Institute for Health and Care Excellence (NICE), 2016). Older patients may have additional needs during stoma care education, including consideration of visual impairment or reduced dexterity (Colostomy UK, 2017). It is essential that a holistic assessment approach be adapted to the individual to optimise their acceptance of a stoma and engage them with postoperative and ongoing care, aiming to maintain their independent lifestyle and promote mental health and wellbeing.
The enhanced recovery programme after surgery (ERAS) is an evidence-based programme that uses a multidisciplinary approach to optimise patients’ health and wellbeing, both pre- and post-operatively, with the aim of reducing surgical stress on the patient (Gustafsson et al, 2012). By using such surgical methods, the length of hospital stay can be reduced, and patients can be supported to return home to continue recovery. This article aims to help community nurses understand the patient's journey before and after the operation, so they can continue to support patients at home.
Preoperative preparation
Education
At the preoperative stage in the patient's journey, it is essential to discuss stoma education; this would routinely be completed in clinic at the stage of surgical consent with the consultant and colorectal nurse specialists (CNSs) present. At this appointment, it is essential that the patient understands the indication for surgery and need for formation of a stoma in order to provide informed consent (Nursing and Midwifery Council (NMC), 2018). The discussion and documentation should include information around the type of stoma to be formed (whether it is an ileostomy, colostomy or urostomy), which would enable the patient to make a well-informed decision and begin the acceptance process around stoma formation (NMC, 2018). The patient should understand whether the stoma will be permanent or temporary, and aim to have realistic expectations of postoperative management, as well as understand the risks of both short- and long-term complications (Burch, 2008). Additionally, the patient should be aware of the intent of surgery (curative or palliative), and the use of suitable educational materials with the support of the CNS can aid acceptance of the stoma (Burch, 2008). Sharing of this information in the preoperative stage provides older patients time to comprehend the information and helps reduce the length of hospital stay when they are admitted (Burch, 2008).
Patient concerns should be addressed in order to demystify the process, as well as to ensure that quality of life is maintained and minimally affected by stoma formation (Coloplast UK, 2019). Use of a validated quality-of-life assessment tool may aid in identification of areas to be addressed pre- and post-operatively, with a view to maintaining the older patient's mental health, wellbeing and continued independence (NICE, 2016).
The preoperative stage can be an overwhelming and emotional time for patients and family members; however, the transition can be eased with support and the provision of recommended educational materials on stomas and their care. An open conversation should be had early in the patient's journey, to identify supporting family members or carers who may be involved in stoma care, as well as to establish what level of care they feel able to deliver.
To prepare the patient and their family to accept and cope with stoma care, a stoma practice pack can be provided to aid education around the practicality and familiarity of products, including pouches to trial at home. The patient and their family can have the time to review products and even wear them at home to simulate how it would feel when the actual stoma is present. This could help support and prepare the patient psychologically for the impact of surgery and the change in body image (Taylor, 1999).
Preoperative optimisation
Patients over 65 years of age may have signs of frailty, including limited mobility, dexterity, memory loss, weight loss, changes in skin integrity and visual impairments, among other comorbidities. Ensuring preoperative optimisation is essential, and may involve routine health checks and assessment for allied health involvement, with completion of any appropriate referrals (Colostomy UK, 2017).
Nutrition
Preoperative nutritional status should be thoroughly assessed, due to the increased risk of frailty, malnutrition, poor dietary intake and, potentially, obesity in the older population (Baczynska, 2018). Good nutritional intake should be promoted to reduce the risks of complications, such as wound infections. The ERAS programme minimises the perioperative fasting period, with provision of carbohydrate-rich drinks to limit dehydration, thirst and anxiety prior to surgery, as well as to provide nutrition for short-term maintenance of body mass and muscle strength (Gustafsson et al, 2012).
Postoperative care
Early oral intake and mobilisation postoperatively are promoted through ERAS, with the aim of reducing complications and restoring bowel function (Burch, 2008). Through preoperative counselling and participation in ERAS, the patient should be prepared and aware of their postoperative plan.
Stoma training begins on day one postoperatively on the inpatient ward, using a patient-centred, multidisciplinary approach to identify practical, emotional and social issues concerning stoma care. This enables further training to be tailored to each patient and their identified needs, improving their independence and confidence in stoma self-management (Burch, 2008).
The ageing process can lead to multisystem dysfunction and accumulation of morbidities, with resultant frailty and deterioration in function (Nigam and Knight, 2017). This, in addition to perioperative environmental, medication and other physiological changes, including dehydration, promotes the risk of delirium in the older patient. Hence, in the perioperative period, older patients may demonstrate a change in normal behaviour and cognition, which may require an adaptable approach from the carer delivering stoma care education. Information should be delivered in a format suitable for the patient and their carers at that point in time, with a stress on the importance of regular contact with the CNS to alleviate psychological stress and provide physical, practical support where necessary.
Regular training sessions promote the development of a familiar routine for the patient (Burch, 2008). Limiting the number and variety of accessories and products being used by the patient may simplify this routine, particularly in patients with transient or even long-standing cognitive impairment.
Adapting the teaching of stoma care to patients’ needs is essential. Ensuring that appropriate glasses are worn, hearing aids are in place and other aids are accessible as required contributes to effective communication and education. In particular, patients may struggle with the practicality of cutting stoma products due to issues around dexterity. Multiple approaches can be taken to resolve this issue, including early involvement of family and carers who can assist with stoma care and the use of pre-cut products, which will allow the patients to apply the pouch by themselves. Frequently reviewing the type of pouch system may be appropriate, as some patients may find the use of a two-piece system easier. This requires the patient to only change the pouch, and less frequent care is required for the base plate, thus allowing maintenance of independence and lifestyle (Burch, 2008).
Age-related skin changes need to be assessed and may inform product choice; with ageing, the skin becomes thinner and fragile, and it is likely to have reduced turf with wrinkles and creases, and is overall at a greater risk of trauma (Nigam and Knight, 2017). These issues, in conjunction with a suboptimal product, may lead to pouch dysfunction or leakage. Use of certain accessories can promote skin health, such as an adhesive remover to reduce trauma on removal of appliances; similarly, a wipe or spray may be used, depending on patient dexterity.
Keeping active after the stoma surgery is strongly advocated, as it has several benefits to the patient, both physically and psychologically (Department of Health and Social Care (DHSC), 2011). Initially, gentle mobilisation is recommended, which can help reduce anxiety, postoperative muscle wasting and the risk of deep vein thrombosis. Once the patient is fully recovered from surgery, it is recommended that those over 65 years of age engage in 30 minutes of moderate activity over a 5-day period; the benefits of this include maintenance of physical health, improved self-esteem, reduced risk of falls and maintenance of mood and cognitive function (DHSC, 2011).
Discharge
At the time of discharge, the patient should be stoma competent as an individual or with family or carer support. Through early stoma training, the patient will probably show enhanced physiological adaptation to the newly formed stoma, but emotional adaptation could take longer.Therefore, ongoing assessment is essential within the community setting (Burch, 2008). All relevant discharge information and contact numbers for service support should be provided and explained, so the patient can refer back for guidance at home. This ensures that the patient does not feel vulnerable or isolated while adapting to the new stoma. Follow-up appointments for review of the stoma site should be completed in order to monitor patients’ physical and psychological adaption to the newly formed stoma, thus ensuring that quality of lifestyle is maintained and monitored through validated assessment tools (Coloplast UK, 2019). Referrals to community nurses for stoma review and support should also be made at the point of discharge in accordance with local guidelines; this will help the community setting can help the patient to manage their ensure that stoma management has continuity of care and support (Taylor, 1999). Following the discharge plan within stoma independently in the long term and maintain their independent lifestyle in the rehabilitation phase, as it provides psychological and educational support to help aid acceptance of the stoma (Burch, 2008). It can be an isolating time when the patient is back in their own home environment, so ensuring that support is provided through home visits and close monitoring is recommended.
Conclusion
Older patients require a specific approach to stoma care and education, due to their potentially pre-morbid health status. Advancing age presents challenges in both the practical and psychosocial aspects of stoma management, which can be addressed with ERAS in order to preserve function, independence and mental health wellbeing.