Overview of stoma care for community nurses

For nurses, it is common in the acute ward and community environments, as well as in palliative care, to care for patients with a colostomy. Therefore, it is important to have an overview of its use and any complications.

Overview of stoma requirement

A colostomy is needed to treat conditions such as bowel cancer, Crohn's disease, diverticulitis; anal, vaginal or cervical cancer; bowel incontinence; and/or Hirschsprung's disease (NHS, 2017). Colostomy and ileostomy are the most common forms of stoma but a gastrostomy, jejunostomy, duodenostomy or caecostomy may also be performed (National Institute for Health and Care Excellence (NICE), 2020). The present article focuses on colostomies but also provides general information about the care of the stoma site and other factors that are relevant across all types of ostomies, such as medications, complications, diet and exercise.

A colostomy is made after a section of the colon has been removed and the bowel cannot be rejoined. It can be required if the person cannot pass stool through the anus because of illness, injury or a problem with the digestive system. A colostomy may be temporary and followed by a colostomy reversal at a later date, or may be permanent. Surgeries include loop colostomy, whereby the patient has two stomas, or end colostomy, where the patient has only one stoma.

Colostomy appliances overview

According to the NHS (2017), a colostomy bag would require changing one to three times a day, when full. However, other bags, known as ‘drainable bags’ (Box 1), can be used, which can be replaced every one or two days and are more suitable for people with very loose stools (NHS, 2017).

Box 1.Examples of drainable bags available in the UK

The stoma nurse usually sees the patient before and after the colostomy operation and helps the patient choose their preferred equipment. However, for community nurses it is important to be aware of the type of appliances they might come across so they feel confident in recognising various stoma devices. For example, there is a one-piece pouch, where the bag and flange (the part that attaches to the skin) are joined together and the appliance is removed when full and disposed of. Alternatively, there is a two-piece pouch, where the bag and flange are separate but can be connected, and the flange can remain attached to the skin for several days, and the bag can be removed and disposed of several times a day (NHS, 2017). The appliances used for stomas are made from hypoallergenic material to reduce chances of irritation, and contain filters to avoid unpleasant odours coming from the bag. Some patients may be so used to their stoma and their bowel habits that they may choose not to wear a bag. They should instead be advised to wear a cap due to leakages, which can happen occasionally. The patient's mental state and neurological deficits should be considered in case they are less aware about the management of their stoma. For example, they may forget to change the bag. Therefore, it is important that they have the right care package or a family friend, relative or carer to assist with the management of their stoma.

Other appliances or aids used for colostomy patients include: support belts and girdles, deodourisers (charcoal) that are inserted into the appliance, protective skin wipes, sprays for adhesive removal, protective stoma rings and underwear and swimwear specifically designed for stoma patients. The stoma nurse would be the point of contact for such aids or appliances (NHS, 2017).

In terms of supplies, the patient would be given an initial supply, as well as prescriptions, prior to leaving hospital. If they have lost the details, it is important for the community nurse to then contact the ward and ensure the patient not only has a designated stoma nurse they have been referred to, but that they are able to have access to appliances and have continuing prescriptions for these. When dealing with prescriptions, it is important to be aware that the patient can have these filled in at a local chemist, although there is also the option of sending these to a specialist supplier who can post the items, whereby prescriptions are free of charge for permanent colostomies (NHS, 2017). If the colostomy is temporary but the patient is aged over 60 years or receiving cancer treatment, then the prescription fee would be waived. Others with a temporary colostomy should be advised to buy the cost-effective option of a prescription prepayment certificate, which represents a fixed sum of money every year irrespective of the number of prescriptions are required in that year (NHS, 2017).

Colostomy irrigation

Some patients may choose to irrigate their colon with water every day or every other day as an alternative to wearing an appliance around the stoma site. To do this, a small device is inserted into the stoma, with a bag full of water attached, whereby the water would then slowly be squeezed into the colon to irrigate it, with a cap covering the stoma between irrigations. There are several benefits to this option: the patient can choose when to perform the irrigation, and no appliance except the cap is required; further, the patient can enjoy a more varied diet, and flatulence is less common (NHS, 2017). However, a limitation to this method is that it takes 45–60 minutes to complete. Additionally, it needs to be carried out at the same time every day, which may be difficult to commit to, with their work, personal and social life to consider. The technique is not suitable for people with Crohn's disease or those with diverticulitis, or for those undergoing radiotherapy or chemotherapy (NHS, 2017).

Clinical standards for stoma care

There are specific clinical standards that have been developed and reviewed by a group of experienced specialist stoma care nurses from a corporate nursing team, in conjunction with the Royal College of Nursing (RCN) (SecuriCare, 2019). These are a practical working tool for stoma care, divided into four main evidence-based sections regarding preoperative care, postoperative care, discharge planning and continuing care.

An audit on service delivery is regularly carried out through Patient Reported Experience Measures (PREM), which also supports service development (SecuriCare, 2019). The standards can also be used as the basis of a structured teaching tool. The Nursing and Midwifery Council (NMC) (2018) stated that a registered practitioner must: provide a high standard of practice and care at all times, deliver care based on the best available evidence or best practice, keep clear and accurate records relevant to practice. The 6 C's (NHS England, 2012)-care, compassion, courage, communication, commitment and competence-are embedded throughout these clinical nursing standards. These are fundamental values that underpin and inform every aspect of clinical practice. SecuriCare (2019) explained that they strive to achieve their aims by producing these standards that support their stoma specialist nurses. The stoma specialist nurse would be expected to provide ongoing support and advice in the community to those who have a stoma, addressing their biopsychosocial needs, facilitating their independence in the management of their stoma and maintaining the health of the stoma while avoiding complications (SecuriCare, 2019).

The standards state that:

‘… when patients carry out self-care and equally feel supported in doing so, they are more likely to have greater confidence and a sense of control, to have better mental health and less depression and to reduce the perceived severity of their symptoms.’

(SecuriCare, 2019)

The standards also state that the stoma nurse should provide a responsive, easily accessible follow-up service, and that they should offer the patient follow-up appointments at regular intervals to re-assess their needs (SecuriCare 2019). Further, the stoma nurse is expected to provide appropriate information and advice on relevant lifestyle issues while taking into consideration the individual's cultural and religious beliefs, as well as providing ongoing psychological support. The nurse is expected to communicate with other members of the health and social care teams to address any identified needs of the stoma patient, while documenting all interactions in the appropriate healthcare records (SecuriCare, 2019). The guidelines also state that information should be given to the patient about local support groups and that advice should be tailored to their needs considering their cultural and religious beliefs.

Medications that may need modifying for the stoma patient

NICE (2020) has issued British National Formulary (BNF) guidance with regard to stoma care options when considering treatments. It is useful for community nurses to be familiar with these if they come across patients requiring stoma care.

Enteric-coated and modified-release medicines are unsuitable for stoma patients, especially those with an ileostomy, due to there not being sufficient release of active ingredients. Soluble tablets, liquids, capsules or uncoated tablets are more suitable for stoma patients, as they dissolve more quickly but, where solid dose forms have been given, the ostomy bag contents should be checked for any remnants (NICE, 2020). The BNF guidance issued by NICE (2020) also stated that sorbitol preparations should be avoided as they have laxative side effects.

It is important to be aware that opioids may be unsuitable due to the common troublesome issue of constipation as a side effect, and that paracetamol is more suitable. NSAIDs may not be useful due to their side effects in irritating the gut lining and causing bleeding and, if these have been taken by the patient, then faecal output should be monitored for signs of any blood (NICE, 2020). Magnesium salts may cause diarrhoea, and aluminium or calcium salts may cause constipation in stoma patients. Proton pump inhibitors and somatostatin analogues, such as octreotide and lanreotide, can be administered to reduce the risk of gastric acid secretion in increasing stomal output. To decrease the risk of diarrhoea, the patient may be prescribed loperamide or codeine phosphate. The patient may become hypokalaemic if taking digoxin, due to fluid and sodium depletion, and thus a potassium supplement or potassium-sparing diuretic, such as spironolactone, may be prescribed, but with monitoring for early signs of toxicity (NICE, 2020). Diuretics should be used with caution, as they may cause excessive dehydration, leading to potassium depletion. This is another reason to prescribe a potassium-sparing diuretic (NICE, 2020). Medication such as iron preparations can loosen the stool and make the skin sore. Therefore, if iron is a requirement for the patient, they should ideally be taking an intramuscular iron preparation, and modified-release preparations should be avoided (NICE, 2020). Laxatives should not be used by patients who have an ileostomy, as they may cause a rapid and severe loss of water and electrolytes (NICE, 2020). Constipation may occur in those with a colostomy but, wherever possible, it is crucial that it be treated with an increase in fluid intake or dietary fibre as opposed to using laxatives. However, for colostomy patients bulk-forming drugs can be tried. If these do not work, a small dose of a stimulant laxative, such as Senna, could be used with caution (NICE, 2020). In terms of potassium, liquid supplements are preferred to modified-release preparations, with a daily dose split to avoid osmotic diarrhoea.

Diet and exercise

It is important to understand the patient and their dietary requirements when visiting them in the community. They may not see the stoma nurse often, or may be stuck in old habits due to loneliness and isolation, causing their mental health to perhaps be destabilised. They may even have neurological deficits or could be forgetful.

In the first few postoperative weeks, the patient would be advised to consume low-fibre foods only, since high-fibre foods increase the size of stools, which may then block the bowel. A normal diet can usually be resumed after eight post-operative weeks. A healthy balanced diet should then be encouraged, with plenty of fresh fruit and vegetables, and foods that were once banned on a restricted diet can be reintroduced to the diet at this point (NHS, 2017).

It is important to reassure the person with the stoma about the sensitive topic of the smell of the stoma. Stoma smells are often perceived to be stronger by the patient who wears the stoma than by others. Additionally, stoma patients often have a lot of wind at first following the operation, and they should be reassured that this does diminish with time. Community nurses should advise their patients to get in touch with the stoma nurse if diet or wind is becoming an issue requiring more specialist input.

Postoperatively, gentle exercise is recommended to aid recovery, and how well recovery takes place is determined by how much exercise the person can do. All colostomy bags are waterproof so swimming is possible and resuming the normal exercise routine should be encouraged once recovery has taken place, with, of course, the exception to exercise being if the patient is experiencing pain, in which case their specialist should be contacted in case of complications, unless it is in the initial postoperative stage where this would be expected if the patient is doing too much.

Complications

An awareness of complications is integral so that community nurses feel confident in knowing when to refer to the specialist/stoma nurse and what they can do to help or advise patients in the meantime.

Rectal discharge may be experienced where the rectum and anus are intact, due to the bowel continuing to produce mucus despite this no longer being required. The longer the remaining section of bowel is, the more mucus the patient may be producing, with a frequency of several times a day to once every few weeks (NHS, 2017). The time to contact the GP would be when pus is observed, as this is an indicator of possible infection or tissue damage.

Advice that can be given regarding this sensitive topic would be to sit down on the toilet and to push as if passing a stool, which can remove the mucus and prevent the build-up of a ball of mucus. This may be difficult because surgery reduces the sensation in the rectum, in which case, the GP should be contacted for further treatment. Something that can often help would be glycerin suppositories, which help to make the mucus more watery and, therefore, easier to pass. Alongside a problem with mucus would be the problem of skin irritation, which can be helped with the use of a barrier cream.

A parastomal hernia may also occur, whereby the intestine pushes through the muscle surrounding the stoma, resulting in a bulge that can be seen protruding against the skin. To reduce the risk of complication, the patient can be advised to wear a support garment, such as a belt or underwear, avoid heavy lifting and straining, and to maintain a healthy weight, since obesity is associated with a greater chance of this complication occurring (NHS, 2017). The hernia would not usually cause the patient pain, but it may complicate the ease with which the appliance can be worn. The stoma nurse can help with this but, in some cases, surgery may be required. The hernia may yet recur; therefore, advice given by the community nurse to remind the patient of how to avoid such a complication in the first place can be extremely useful.

A blockage may occur in the stoma if there is a build-up of food. It is important to be aware of the signs of such a complication, which include: not being able to pass many stools, passing of watery stools, abdominal bloating and swelling, stomach cramps, a swollen stoma, and nausea or vomiting (NHS, 2017). The stoma patient should be advised that, where a blockage is suspected, they should avoid eating a solid diet for the time being, drink plenty of fluids, massage the abdomen and area surrounding the stoma site, lie on their back with knees pulled to the chest and roll from side to side for a few minutes, and to take a warm bath for 15–20 minutes to relax the abdominal muscles (NHS, 2017). This is an extremely important issue to be aware of as the colon is at risk of bursting if the problem does not cease within 2 hours and no medical attention is paid. The stoma nurse should be contacted urgently in such cases, or the patient should be taken to the emergency department. Useful advice that can be given to the patient to prevent such a complication would be to chew food slowly and thoroughly, to drink plenty of fluids and to avoid eating large amounts of food at one time. Foods known to increase the likelihood of stoma blockage are: corn, celery, popcorn, nuts, coleslaw, coconut macaroons, grapefruit, dried fruit, potato skins, apple skins, orange pith, bamboo shoots and water chestnuts (NHS, 2017).

Other complications to be aware of include skin problems, stomal fistula, stoma retraction, stoma prolapse, stomal stricture, leakages and stomal ischaemia. These can be addressed by seeking urgent advice from the named stoma nurse for the patient and by informing the GP alongside this communication.

Psychological needs

It is important to cover any psychological needs of the patient when providing stoma care. They may be too anxious to explain that they are struggling mentally to adapt, and community nurses are in a good position to discuss with patients how they may feel and validate their feelings when the patient opens up to them. The patient may even be struggling to the point that they need referral for counselling, and they may have mental health issues already. Having a stoma comes with loss of self-esteem unless the person is able to adapt well through being able to discuss how they feel with an understanding nurse, family member or friend. They also should be given the means to go about their life as normal, through provision of the correct appliances, medication and knowledge of what the stoma entails. If the patient is confident about their diet and exercise, they may start to feel more in control and able to adapt, while maintaining good nutrition and physical activity, which has proven benefits for the mind (Mayor, 2017; Heidari et al, 2019). It may take some time to get used to, and it may also introduce various complications for the patient's sex life, which would inevitably have some psychological consequences for the person. More information can be found on the website Stoma Tips for details on this sensitive subject (www.stomatips.com). The patient may be used to their community nurse and trust them enough to discuss this subject with them.

Conclusion

Overall, there are multiple factors to consider when caring for patients with stomas. It is good practice for community nurses to have a general knowledge of stomas and ostomies, so complications or medication issues may be noticed and it can be known when to appropriately refer the patient to the stoma nurse. Community nurses can also help care for the stoma site in patients who may be less able physically or mentally, in order to avoid complications occurring. General advice on diet and exercise can also be reiterated by the community nurse, as well as caring for the patient's psychological needs.

KEY POINTS

• Stomas are required for many reasons, including complications due to a range of diseases and cancers
• Medications and diet may need modification for the newly postoperative stoma patient
• There are a range of aids and appliances for the stoma site, or the patient may choose to irrigate the bowel with water through the stoma site, wearing a cap rather than a bag
• A stoma nurse is a clinical nurse specialist who should be referred to for any queries and specialist advice
• Challenges in the care of stoma patients include management of complications, with additional physical and psychological needs.

CPD REFLECTIVE QUESTIONS

• What are the considerations that need to be made when caring for the stoma patient in the community?
• Consider a patient on your caseload, and think about holistic care provision in considering their physical and mental health needs
• How would you recognise and care for a patient who appears to have a newly formed parastomal hernia, and what advice you would give to other patients in how to avoid such a complication occurring?