By Beth Hoffmire Heideman, MSN, RN

No one wants an ostomy, but sometimes it’s required to save a patient’s life. As ostomy specialists, our role is to assess and intervene for patients with a stoma or an ostomy to enhance their quality of life. We play an active role in helping patients perform self-care for their ostomy and adjust to it psychologically, starting even before surgery.

Preoperative considerations

Preparation for the ostomy is the most critical aspect of a healthy adjustment. When the ostomy is planned, the patient and family members are more likely to process the life changes it will entail. They can learn about anticipated postsurgical changes in the patient’s diet, clothing, and sexuality, and family members can become more sensitive to the change in their loved one.

Assessment

On initial assessment, evaluate your patient’s body configuration, stoma placement, skin integrity, physical limitations, psychological needs, and home caregiving system. Then develop a plan of care to mitigate problems that could impede the patient’s ability to maintain and manage the ostomy system.

The human body comes in many configurations and sizes. Because each person’s body is unique, clinicians may need to get creative to adapt the ostomy system to a patient’s body. Options for adapting it to your patient’s physical characteristics include using:

• a one-piece vs. a two-piece system
• a flexible flange, clear drape flange, or moldable flange.

Factors affecting decisions about an ostomy include its location, skin integrity, and physical ability. (See Decision guide for ostomy products.)

Location

The stoma may be located near an incision, under a peniculum, or in an abdominal fold. Ostomies in these areas can be hard to manage because of wound dressings, staples, adhesive strips, and body shape.

If the ostomy system is located next to an incision, you may want to adapt it by using stoma paste strips, moving the flange opening to the right or left, or using a pectin-ring stoma system without a flange. When the stoma is placed under a peniculum, pressure from the weight slows effluence (drainage) flow. To decrease pressure on the stoma and promote flow, an abdominal support binder can be used. (See Case study 1: Stoma location challenge.)

If the stoma is located in an abdominal fold, you can use a one-piece flexible ostomy system to increase adherence. When needed, add stoma paste strips and either medical adhesive spray or a bonding cement.

Skin integrity

Always consider skin integrity when choosing an ostomy system. Take into account the patient’s fragility from such factors as age, medications, an irregular abdominal plane from previous surgeries or scarring, moisture or oily skin that limits flange adherence, and comorbidities (such as psoriasis, fungal infections, and ulcers). Options for maintaining skin and ostomy-system integrity include use of crusting, silicone flanges, stoma paste strips, or topical medication covered with hydrocolloid or extended-wear products.

Physical abilities

Be aware that a patient with limited muscle function may have limited gross and fine motor skills, which makes self-care a challenge. Expect patients with such conditions as multiple sclerosis and muscular dystrophy to have limited strength. Those with amyotrophic lateral sclerosis, Parkinson’s disease, or stroke are likely to have limited muscle control. In each case, rehabilitation support and physical or occupational therapy can help the patient learn how to adapt to the stoma.

Psychological adjustment

Hidden issues can make it hard for patients to adjust to the ostomy system. The patient who undergoes an unplanned ostomy has to relearn life skills while grieving the change in self-image and dealing with a sense of having an imperfect body, loss of control, or feeling like an infant. To this patient, the ostomy system may become the enemy, so to speak. The patient may refuse to learn about self-care and ignore ostomy complications. To help patients regain a sense of control, clinicians must address body image with them and provide education.

The following interventions can help the patient focus on the positive:

• Suggest that the patient keep a diary of daily activities.
• Listen actively as the patient expresses thoughts and feelings.
• Confront false ideations, such as “I’m a baby now,” “No one will ever touch me again,” or “I smell” with such positive statements as “I’m still an adult,” “My wife loves me,” or “I can use deodorizers to make sure the ostomy doesn’t smell.”
• Recommend ostomy support groups or spiritual or psychological counseling.

Mental illness

Mental illness also can cause ostomy management problems. Mentally ill patients may respond differently to an ostomy than other patients, leading to lack of proper ostomy self-care. If mental illness goes unrecognized and unaddressed, the stoma or peristomal skin may become damaged.

As a wound care clinician, be sure to carefully review reports of unresolving ostomy malfunction issues, note their frequency, and observe malfunction patterns. When these malfunctions occur consistently, assess the patient for mental illness and provide a referral to appropriate support services. (See Case study 2: Effect of psychological distress on ostomy care.)

Depressed patients may avoid the stoma or ostomy system. They may fail to apply the system or, conversely, leave it on for extended periods to avoid thinking about the body-image change it represents. On the other hand, highly anxious patients may be hypervigilant and remove the ostomy system frequently to check on the stoma. In patients with either depression or high anxiety, the stoma and peristomal skin may break down.

Bipolar patients may have difficulty learning about self-care because of their high or low affect. They should receive care from a mental health specialist, along with appropriate medications, to support their ability to learn and adjust to the ostomy.

Unmedicated schizophrenic patients may have trouble processing the presence of a stoma. They may perceive the stoma or ostomy system as alien and attack it, injuring themselves or damaging the stoma or peristomal skin. This response demands careful mental health observation and medication monitoring to prevent further bodily harm.

Home caregivers’ behavior

The patient’s home caregivers also may be a hidden cause of ostomy system problems. They may be unable to accept the change in their loved one, and their negative reactions may result in the patient’s failure to perform self-care. This lack of self-care reflects the patient’s distress. Observe carefully for disharmony among caregivers and address any issues. Through active listening or referral to a support group or counseling, you can help ease negative behaviors.

Financial constraints

If because of complications, your patient needs additional ostomy supplies beyond what the insurance company allows:

• Ask the physician to write a letter of medical necessity to the insurance company and vendor that explains the reason for product overage.
• Contact the ostomy supply vendor to request free samples.
• Contact ostomy support group members, who may be able to provide samples.

Overcoming adversity

A patient with a malfunctioning ostomy system or a maladaptive response to it can pose a challenge for the ostomy management specialist or the wound, ostomy, and continence nurse. But with careful planning, monitoring, and creativity, such challenges can be overcome so the patient can have the highest possible quality of life.

Selected references

Baranoski S, Ayello EA. Wound Care Essentials: Practice Principles. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.

Johnson RJ. Finding Health: A Search for Wellness and Longevity. CreateSpace Independent Publishing Platform; 2011.

Shulman L. Brooks/Cole Empowerment Series: The Skills of Helping Individuals, Families, Groups, and Communities. 7th ed. Brooks/Cole Cengage Learning; 2009.

Taylor SG, Renpenning K. Self-Care Science, Nursing Theory and Evidence-Based Practice. Springer Publishing; 2011.

Townsend MC. Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice. 8th ed. Philadelphia, PA: F.A. Davis; 2105.

Wound, Ostomy and Continence Nurses Society (WOCN). Colostomy and Ileostomy Products and Tips: Best Practice for Clinicians. Mt. Laurel, NJ: WOCN; 2013.

Wound, Ostomy and Continence Nurses Society (WOCN). Peristomal Skin Complications: Best Practice for Clinicians. Mt Laurel, NJ: WOCN; 2007.

Wound, Ostomy and Continence Nurses Society (WOCN). Stoma Complications: Best Practice for Clinicians. Mt. Laurel, NJ: WOCN; 2014.

Beth Hoffmire Heideman is a wound care nurse at McAuley Seton Home Care in Cheektowaga, New York.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.