Colostomy and ileostomy are the most common forms of stoma, but a gastrostomy, jejunostomy, duodenostomy or caecostomy are not uncommon (National Institute for Health and Care Excellence (NICE), 2020).
A colostomy is a procedure to bring part of the colon to the surface of the abdomen. The opening made in the abdominal wall during this procedure is known as a stoma. This may be permanent or temporary. In the case that it is temporary, it is followed by a colostomy reversal at a later date. Surgeries include loop colostomy, whereby the individual has two stomas, or end colostomy, where the individual has only one stoma.
The stoma nurse will usually see the individual before and after the ostomy operation and will help choose their preferred equipment. They will also assist with prescription of supplies; in the case of a permanent ostomy, they are exempt from a prescription fee. In the case of a temporary ostomy, they can be purchased on a prepayment prescription certification.
Colostomies, for example, would usually need bag (the most common appliance associated with this procedure) changing one to three times a day, when full. However, other bags can be used, known as ‘drainable bags’, which can be replaced every 1-2 days, which are more suitable for people with very loose stools (NHS England, 2017).
The appliances used for stomas are made from hypoallergenic material to reduce chances of irritation and contain filters to avoid unpleasant odours.
The individual’s mental state or neurological deficit should also be considered in order to avoid complications and to safely manage the stoma site. Therefore, it is important to consider who may be required to assist with stoma care and what appliances are most suitable, which the stoma nurse and specialist nurse will have organised for the individual. Community nurses, however, play an integral part within the system of communication and care, as they can support the individual and their family and liaise with specialists, as required.
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, in conjunction with the Royal College of Nursing (Securicare, 2019). These are considered a practical working tool, closely aligned with the brand’s introduction pathway 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’s (NMC) ‘The Code’ (NMC, 2015) state 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 six C’s (NHS Commissioning Board, 2012) are embedded throughout Clinical Nursing Standards: Care; Compassion; Courage; Communication; Commitment; and Competence. These are fundamental values that underpin and inform every aspect of clinical practice. Securicare (2019) explain that they strive to achieve such aims by producing these standards that support the Securicare specialist nurses. The stoma specialist nurse would be expected to provide ongoing support and advice in the community to people with a stoma, addressing their biopsychosocial needs, facilitating their independence in the management of their stoma, maintaining the health of the stoma and 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.’
(Mathers et al, 2011; in Securicare, 2019)
The stoma care nurse can provide the stoma patient with continuing support to help them maintain stoma-related health and well-being. The standards state that the stoma nurse should provide a responsive, easily accessible follow-up service, and that they should offer the individual follow-up appointments at regular intervals in order to reassess the individual’s needs (Securicare, 2019). The Securicare (2019) standards also indicate that the stoma nurse would be 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 would be expected to communicate with other members of the health and social care teams in order 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 individual about local support groups and that advice should be tailored to their needs in consideration to their cultural and religious beliefs.
Modifying medications for the stoma patient
NICE (2020) have issued the British National Formulary (BNF) guidance in regards to stoma care options when considering treatment. It is important to be familiar with these guidelines when coming across individuals with a stoma in the community.
‘Understanding the type and extent of surgical intervention in each patient is crucial in managing the patient’s pharmaceutical needs correctly.’
Enteric-coated and modified-release medicines are unsuitable for stoma patients, especially in those with an ileostomy, as there is insufficient release of active ingredients. Soluble tablets, liquids, capsules or uncoated tablets are more suitable for such individuals as they dissolve more quickly, but where solid dose forms have been given, the ostomy bag contents should be checked to see for any remnants (NICE, 2020). The BNF guidance issued by NICE (2020) also states that sorbitol preparations should be avoided as it has laxative effects.
It is important to be aware that opioids may be unsuitable due to constipation being a common troublesome side effect and that paracetamol is a better option. Non-steroidal anti-inflammatory drugs may not be useful as they can irritate the gut lining and cause bleeding, and if these have been taken by the individual, then faecal outputs 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 given to reduce the risk of gastric acid secretion in increasing stomal output. For decreasing the risk of diarrhoea, the individual may take loperamide or codeine phosphate. The individual may become hypokalaemic if taking digoxin, due to fluid and sodium depletion and therefore, a potassium supplement or potassium-sparing diuretic such as spironolactone may be given, but while monitoring for early signs of toxicity (NICE, 2020). Diuretics should be used with caution, as they may cause excessive dehydration, thus leading to potassium depletion. This is another reason to give a potassium-sparing diuretic (NICE, 2020). Medication such as iron preparations can loosen the stool and make the skin sore. Therefore it is important that individuals who require iron should ideally take an intramuscular iron preparation, while avoiding modified-release preparations (NICE, 2020). For clear reasons, laxatives should not be used in individuals who have an ileostomy, as they can cause a rapid and severe loss of water and electrolytes (NICE, 2020). Constipation may occur in those with a colostomy, but it is crucial this is treated with an increase in fluid intake or dietary fibre as opposed to using laxatives. However, for colostomy patients, bulk-forming drugs can be indicated, but if these do not work, a small dose of a stimulant laxative such as Senna could be used with caution (NICE, 2020). Potassium supplements, such as those in liquid-form are preferred to modified-release preparations, with a daily dose split in order to avoid osmotic diarrhoea.
Diet and exercise
It is important to understand the dietary requirements of individuals in the community prior to visiting them. They may not see the stoma nurse often, or may be stuck in old habits due to loneliness and isolation, which can also affect their mental health. They could also have a neurological deficit and can therefore be very forgetful.
In the first few weeks post-operation, the individual will be advised to consume low-fibre foods only, as high-fibre foods can increase the size of stools, which may then block the bowel. After approximately 8 weeks, a normal diet can usually be resumed. 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 (NHS England, 2017).
It is important to provide reassurance on the sensitive topic of smell for people with a stoma. This smell is often perceived to be stronger by the individual with the stoma than by others. Also, soon after the operation, the stoma patient often has a lot of wind, but they can be reassured that this will slowly diminish with time. As a community nurse, one can advise the individual to get in touch with their stoma nurse if diet or wind are becoming an issue and require further specialist input.
Postoperatively, gentle exercise is recommended to aid in recovery; the extent and speed of recovery is determined by how much exercise the person can do. All colostomy bags are waterproof, so swimming is possible and resuming their normal exercise routine should be encouraged after the initial post-operative stage and once recovery has taken place. The exception, of course, is when the individual is experiencing pain, in which case, their specialist should be contacted to ensure there are no complications.
Complications
An awareness of complications is integral so that as a community nurse, one can feel confident in knowing when to refer to a specialist nurse and what one can do to help or advise the individual with a stoma.
A parastomal hernia can occur, whereby the intestine pushes through the muscle surrounding the stoma, resulting in a bulge that can be seen protruding against the skin. Therefore, individuals should be advised to wear a support garment, such as a belt or underwear, avoid heavy lifting and straining and to maintain a healthy weight, as individuals who are obese are at a greater risk of developing this complication (NHS England, 2017).
Strong et al (2021) noted that the type of stoma may also indicate the probability of certain complications. An incomplete obstruction may be likely in the case of an individual with a high output stoma, and this can also put them at risk of dehydration. Strong et al (2021) advised that oral rehydration solutions are much preferable to water, as water may actually compound the problem. The authors also noted that modified release preparations can be compromised in their ability to work where there is a high volume output from the stoma, as they will not have time to stay within the body to work and will be expelled too quickly, thus lowering the dose the individual was receiving. The authors noted that a pharmacist should be consulted for advice on whether the capsule can at least be opened or the tablet crushed, or perhaps a preparation change would be needed and therefore, a new prescription on the drug chart. The authors also commented that a prolapsed stoma can often be reduced safely in a primary care setting rather than requiring an urgent referral or emergency department visit. Individuals will also find it less painful if they can remove their own stoma bag as opposed to staff attempting this. The removal of the bag would be essential to ensure a complete assessment of the area can take place but the individual must have a replacement bag ready for when the assessment is complete (Strong et al, 2021).
Blockages can be common in the stoma due to a build-up of food. Signs 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 England, 2017). The individual 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 take a warm bath for 15 to 20 minutes to relax the abdominal muscles (NHS England, 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 medical aid is not provided. The stoma nurse should be contacted immediately in such cases, or the individual could be taken/sent to urgent and emergency care services.
Useful advice that can be given to the individual 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 this problem are: corn, celery, popcorn, nuts, coleslaw, coconut macaroons, grapefruit, dried fruit, potato skins, apple skins, orange pith, and Chinese vegetables like bamboo shoots and water chestnuts (NHS England, 2017).
Other complications to be aware of and seek advice on include skin problems, stomal fistula, stoma retraction, stoma prolapse, stomal stricture, leakages and stomal ischaemia.
Psychological needs
An individual may be anxious in adjusting to the changes made to their body, and may worry about risks of complications. The nurse is in a good position to talk through such issues with the individual and support and validate their feelings. It is important to help someone feel confident and non-judgmental of their body’s changes. Stoma patients often suffer a loss of self-esteem, unless individuals are able to adapt well by discussing how they feel with a nurse, family member or friend. Furthermore, if they are given the means to go about their life as normal, through provision of correct appliances, medication, and knowledge of what the stoma entails, their confidence can increase. If the individual is confident about their diet and exercise, they may start to feel more in control of their body and their life, while maintaining good nutrition and physical activity.
Given how common mental health issues are, it is important to look into what mental health services there are; ‘Improving Access to Psychological Therapies’ or charities such as ‘Mind’ often provide support through counselling. There are many people living with mental health conditions or those who have previously suffered from anxiety or depression, and if the nurses acquaint themselves with their mental health history, they may be able to notice risk more easily. Of the psychological effects the individual could be predisposed to, the stoma is a big change to their body and for some, this may trigger an acute psychological effect. Some individuals may show this less overtly than others; however, it is always good to check in with any individual about their mental health so that services can be suggested and referrals can be made to tackle any problem early on.
Conclusion
Overall, there are multiple factors to be considered when caring for an individual with a stoma. 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 the individual can be appropriately referred to their stoma nurse on time. The community nurse should also help care for the stoma site of individuals who may be unable to do so physically or mentally, in order to avoid complications. General advice on diet and exercise can also be reiterated by the community nurse, as well as caring for the individual’s psychological needs.