Presentation on theme: "Stoma Care Nurse Specialist Gateshead Health NHS Foundation Trust"— Presentation transcript:
1Stoma Care Nurse Specialist Gateshead Health NHS Foundation Trust GP Update on Stoma CareHeather WilsonStoma Care Nurse SpecialistGateshead Health NHS Foundation TrustHandouts available for this talk
2Aims of the SessionTo give a brief overview of stoma care management and the support of the patient/family/carerDiscuss the role of the Stoma Care Nurse SpecialistTo discuss a variety of stoma problems that patients may faceTo outline the management of these problems
4HistoryFirst surgical stomas were created on battle casualties in the early in the early 1700sNo documentation of the specific care of stoma patients in the nursing profession press until the late 1930s (Plumley,1939)The first stoma therapist was not a nurse , but a patient. Norma Gill, Ohio,USAIn the UK Barbara Saunders a ward sister, set up the first stoma clinic in 1969.1971 saw the first stoma care nursing posts
5Types of Stomas Over 80,000 people in the UK living with a stoma Stoma greek word for mouthColostomy (wet colostomy)IleostomyUrostomyLoop or end, permanent or temporary
9Reasons for needing a stoma VariedCancer – bowel/rectum or bladderInflammatory Bowel Disease – Crohn’s Ulcerative ColitisDiverticular DiseaseCongenital abnormalitiesBowel ischaemiaIrradiation damage, fistula formation
10Stoma Care Nurse Specialist Some are Colorectal Nurse SpecialistsPresent in all major hospitals in the NESome are community basedStrong network, regional meetings, patient open days, study events, collaborative working/patient referralsSub specialist nurses in Paediatrics and Urology
11Senior Nurse who has undertaken formal training/examination in the field of stoma care/colorectal Clinical and consultative rolePatient advocate, support and educationTeachingManagement, research, audit, change agent
12Stoma Care ManagementTeam approach – specialist nurses, ward and community nurses, medical staff, patient, carers and familyPractical Support – how to look after the stoma and surrounding skin, dietary advice, types of appliances, holiday advicePsychological Support – emotional reaction to this type of surgery, lifestyle issues, sexuality and body imagePreoperative preparation including sitingPost operative support and educationContinued support once patient is discharged into the communityAim is for the patient to become an‘expert’ in stoma management and adapts to life with a stoma
13Stoma Problems Divided into 3 main areas Problems in the management of a stoma e.g. hernia, prolapse, stenosisSkin conditions which may arise due to the stoma or wearing of an appliancePsychological issues
14Post op stoma shrinkage 6 to 8 weeks for stoma to shrink in diameter and spout. Patients may need to change appliance type e.g. ConvexNeed regular review by stoma nurse in the first 2 to 3 months.
15Colostomy Effluent less corrosive to the skin Usual formed stool, closed pouch, 3x dailyTransverse colostomy may need drainableSome patients may opt for irrigationConstipation –diet, fluids, drugs, age, mechanical e.g. Hernia, stricture, adhesionsOral laxatives/microlax enemas/suppositories
16Diarrhoea – right sided/transverse stomas Chemotherapy/radiotherapyInfection – stool sampleDrugs, diet, stress, malabsorption, disease e.g.crohn’s, cancer, sub acute obstructionImodium
17Ileostomy Effluent very corrosive to skin. 1-2 days. Output should be “porridgy”, mls per day. Imodium.Increased/fluidy output –infection, diet, drugsObstruction- foods high in cellulose, adhesions, strangulated hernia, stenosisStoma oedematous, cramps, fluid effluent then ceasesImodiumHigh output stoma litres, TPN, electrolye replacement
18Loop ileostomy can be difficult to manage due to its odd shape, mucus from distal part High output ileostomy – electrolyte drinks, TPN, appliance typeChemotherapy treatment- increasing stoma activity, skin more sensitive, reduced feeling in patient’s fingers
19UrostomyInfection – clean specimen using a fine catheter, or place collecting bottle under clean stoma. Mucus shreds in the urine is normalPH of the urine should be kept between 5 and 7. Ascorbic acid 100mg, cranberry juicePhosphate deposits, Chronic papillomatous dermatitis around urostomies. 50% household vinegar soaks, appliance review.
20Necrosis / Sloughy Stoma Early post op complication, too tight applianceCompromised blood supplyDifficult surgeryPost op stoma bridgeIll fitting applianceIf superficial will slough offUse intrasite gel or orabase paste to aid removal of sloughRefer to surgeon in severe cases
21Necrosis and Dehiscence This picture shows a necrotic stoma which has dehisced from the skin.Treated by applying intrasite gel or orobase paste, covering with stomahesive paste or GX seal and appliance.Severe dehissance may need suturing.
22Stenosis Narrowing of the lumen of stomal outlet Healing of necrotic tissue, dehiscence of stoma, poor surgical techniqueSecure appliancePatient may be taught to dilateSurgical revisionPatients may need convexity type appliance to protect skin or the use of barrier protection sprays and pastes.These two pictures show stenosed stoma.The following picture is after reconstruction of the stoma.
23Retraction Bowel under tension Surgical technique, post op weight gain Can be difficult to manage –skin damage/leaks/difficult for patient to see stoma. Appliance review.Convex products, rings, pastes, beltMay need to change pouch more frequentlySurgery may be indicated
24Parastomal Hernia Affects 40% plus an increasing problem More common in older patientsLoss of muscle toneAppliance reviewSupport garmentObserve patientSurgeryThis is a common condition.Affect the patients lifestyle, clothing, confidence and self-esteem.Problems with appliances adhering to the skin, leaks and sore skin.Patients may need to change type of appliance - larger appliance with wider flange or oval shaped appliance, use a belt or support garment.Not all patients need surgical intervention- if surgery is contraindicated or hernia not causing any problems.
25ProlapseDefined as when a length of bowel prolapses out onto the exterior of the abdominal wallMore common in transverse loop colostomies (larger stoma)Fit larger applianceReduce prolapseSurgical interventionCan be distressing for patient and family. Need reassurance, explanation and support.Severe prolapse will need assessment by surgeon.Risk of damage to the bowel tissue and necrosis.Some patients may not need surgical management and can be managed with larger type appliance, to contain stoma and effluent.
26PancakingColostomy effluent does not fall to the bottom of the pouch, collects around the stoma. Can be difficult to manage.Leaks, frequent pouch changesSore skinOdour issues – blocked filterCover filter, tissue paper in pouch, lubricating gel, diet, 2 piece pouch
27Trauma to Stoma Many causes Most common ill fitting appliance Cause laceration on stoma. Bleeding.Usually heals quicklyUse of special powders e.g. orahesive, hollisterMay need suturingOther causes of traumaSelf-harm- needs careful assessmentMajor bodily trauma e.g. RTApatients can fit adaptations to seat belt tolimit damage to stoma.Contact during sports activities - can use protective stoma shields.
28Over Granulation Occurs at the junction between stoma and skin Can occur at any timeProbably a reaction to irritationBleedingSorenessPowdersSilver nitrateLiquid nitrogenNeed to check size of appliance aperture which may be rubbing on the stoma and causing overgrannulation.If patients are having no symptoms just observe.
29Skin Problems (1) Very common 1/3 of people with colostomies 2/3 ileostomy or urostomy pts experience skin problems Lyon & Smith, (2001)Many causes - poor fitting appliance, flush stoma, poorly sited stoma, hernia, weight gain, pre-existing skin condition e.g. eczemaThese two pictures show quite a flush ileostomy.Spout pointing downwards, effluent which is very corrosive to the skin is leaking under the bag and lifting it from the skin.Result very sore, inflammed skin which can prevent further appliances from adhering.This patient needed a convexity type product where the flange is domed shaped providing extra protection around the base of the stoma and pushing the stoma further out.This reduces the chance of stomal effluent collecting around the stoma a leaking under the bag.Some patients may need the size of appliance aperture reducing so that it fits snugly around the stoma.
30Skin Problems (2) Allergic reaction Allergic contact dermatitis Patch test. Change pouch type.? Refer to dermatologistMay need topical steroid . Lotion, inhalers, nasal sprayMost stoma appliances are designed to be kind to the skin.Some patients can get an allergic reaction as demonstrated in this picture. Treated by changing appliance type/manufacturer.Patients may get a reaction to the plastic - use of cotton covers.Severe reactions may need patch test - refering to a dermatologist.Application of alcohol-based lotions do not interfere with appliance adhesion e,g treatment of psorasis.
31Check stoma spout, abdomen examination Check stoma effluentAppliance reviewMay need barrier spray, wipes or powder to heal skinUse of accessories e.g. Rings/paste , skin creases, dips
32Patient Impact Stoma formation and stoma complications can effect the physical, psychological, sexuality and social well being of the patientLoss of self-esteemChange in body imageLoss of confidenceSocial recluseAffecting work, relationships, social activities / holidaysRegular support especially early in recovery period is vitalEarly assessment of any stomal complication cannot be overestimated.Patients need constant information, reassurance and support.As highlighted the impact of such complications can be dramatic not only for the patient but also for the family as well.
33Patient Support Healthcare Professionals Clinical psychology National and local patient support groups e.g. Urostomy associationOne to one patient supportStoma appliance manufacturers, pharmacy, dispensing appliance contractors
34Conclusion Stomal problems should be assessed holistically Using multi-disciplinary teamNo one simple answer to any of the complicationsPatients need easy access to specialist nurse for ongoing advice and supportNurses need to involve other specialists where appropriate e.g. tissue viability nurse, dietitianDealing promptly and affectively with a problem will minimise patient anxiety and promote adaptation.
35ConclusionStoma care management can be varied, challenging and at times complex.Careful assessment, prompt management and good communication within the team is essential, as is ongoing patient support.The reward is a confident patient who is able to just get on with life.Thank You for listening.There are handouts at the frontEnjoy your lunch.