Care of patients with stomas: the pouch change procedure

Transcription

1 Care of patients with stomas: the pouch change procedure Rust J (2007) Care of patients with stomas: the pouch change procedure. Nursing Standard. 22, 6, Date of acceptance: July Summary This article discusses basic stoma care in relation to management of the pouch change procedure in a ward-based setting immediately following planned stoma-forming surgery. The article highlights psychological and practical preparation of the patient. It describes the equipment that is needed to change a pouch and examines the rationale and evidence base for the procedure. Author Julie Rust is clinical nurse specialist in stoma care, University Hospital of North Staffordshire NHS Trust, Stoke-on-Trent. julie.rust@uhns.nhs.uk Keywords Colostomy; Patient Assessment; Stoma care These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For author and research article guidelines visit the Nursing Standard home page at For related articles visit our online archive and search using the keywords. THE WORD STOMA is Greek in origin and means a mouth or opening (Bekkers et al 1995). Stomas may be used for input or output but for the purpose of this article the author discusses output stomas only. Output stomas, colostomy, ileostomy and urostomy, are formed for several reasons (Box 1) and are fashioned to collect faeces and urine. In the UK, around 20,859 stomas are formed annually and these are split into colostomy (11,002), ileostomy (8,361) and urostomy (1,496) (Coloplast 2006). Patient assessment Patient assessment begins before surgery and assists with early discharge planning. Pre-operative assessment involves identification of a patient s individual needs and concerns to allow for preparation for surgery, and highlights potential post-operative problems. Patient assessment can be separated into two areas: psychological and physical. Psychological preparation Hayward (1975) and Boore (1978) were two early advocates of pre-operative psychological preparation of patients. Later work has supported the value of such preparation (Martin 1996, Borwell 1997, Beddows 1997, Wicker 1995, Kain et al 2000, Hughes 2002). The aim of this early preparation is to reduce anxiety and stress thereby aiding recovery. In relation to stoma care it aims to assist patients to adapt to their altered body image (Price 1990, Salter 1997, Black 2000) and to return them to their individual lifestyles. It may also increase trust and co-operation between the patient and the nurse, thereby increasing the patient s capacity to learn the pouch change procedure and to care for him or herself. Assessment of individuals mental state is also important, especially if they have a previous history of mental illness, for example, depression, as they are at greater risk of psychological problems post-operatively (Wade 1990, White and Unwin 1998). Early identification of such potential problems can help improve the outcome for the patient and prevent delayed discharge. Physical assessment This is important when considering what product to use, teaching methods for self-care of the stoma and reducing complications. Without initial assessment BOX 1 Reasons for stoma formation Bowel stoma formation: Bowel ischaemia Cancer Congenital disorders Crohn s disease Diverticular disease Familial polyposis coli Incontinence Neurological disorders Radiation enteritis (Baxter and Lloyd 2004) Slow transit constipation Trauma Ulcerative colitis Volvulus Urinary stoma formation: Cancer Congenital disorders Incontinence Neurological disorders Trauma october 17 :: vol 22 no 6 ::

2 pre-operatively there is the potential for a poor outcome in relation to self-care. There are several areas to be considered when assessing patients physical capabilities: Manual dexterity and its limitations, for example, loss of limbs and Parkinson s disease tremors. Vision. Skin conditions, for example, psoriasis and eczema. Body contours. Cultural, for example, religious considerations for pouch change frequency, such as prayer five times daily for Muslims when it may be necessary for them to have a clean pouch in situ. Social and occupational considerations in relation to the position of the stoma. An accurate and detailed pre-operative assessment assists the specialist stoma care nurse when siting the position of the stoma. It is essential that the siting of a stoma is only ever undertaken by a person with the necessary skills and training, and by one who continues to practise these skills regularly. This is often the specialist stoma care nurse, although some wardbased nurses may have undertaken training to enable siting of a stoma in the absence of the specialist team. This may occur in the case of an emergency surgical case when the specialist stoma care nurse is not on duty. A poorly sited stoma has implications for the patient s lifestyle and the type of product used. For example, a stoma sited in a skin crease leads to leakage problems and may have a detrimental effect on the patient s quality of life. Stoma (colostomy) ALAMY FIGURE 1 Post-operative assessment This should involve the type of stoma formed, if not already identified before surgery, the condition of the stoma and consistency of the output, which all have implications for the type of product to be used. Immediately following surgery the stoma should be assessed by theatre, recovery staff, and by the nurse who accepts the patient back to the ward. The stoma may be oedematous but should be reddish pink in colour (Figure 1). If any deviations from this are noted they should be reported to medical staff and the specialist stoma care nurse. Depending on the type of stoma the most appropriate bag should be provided for the patient immediately following surgery. For a colostomy or ileostomy this is initially a clear, drainable pouch with a closed pouch being offered to the patient with a descending colostomy once the output has thickened. This can occur once the patient is eating a normal well-balanced diet. However, it should be explained that certain foods may cause looser motions and that drainable pouches are available for continued use if the patient prefers. For an ileal conduit (urostomy) the product should have a tap at the bottom to allow emptying and attachment of a night drainage bag. Preparing a patient to change the pouch Before beginning to teach the pouch change procedure to a patient several factors need to be considered. First, the place in which the teaching session will occur. This needs to be a private area where the patient will feel comfortable in the knowledge that he or she can ask personal questions without the fear of being interrupted. It has to be warm because the patient will need to be partially undressed and have the facility to lock the door or identify that the area is in use to prevent unwarranted access by others. Second, the patient should be informed about who will be changing the appliance and who else may be present during the teaching session. If students or other healthcare professionals need to attend and this frequently happens in teaching hospitals then permission should be obtained from the patient before beginning the session. The patient should be asked and given the chance to decline the presence of others in a discreet manner so that he or she does not feel pressurised into agreeing to have an audience in attendance. The planned outline of the teaching session should also be discussed and an agreement made as to who will perform specific parts of the pouch change procedure. This is especially important if the stage has been reached where a patient has to undertake part, or all, of the pouch change procedure. It is usual for the patient to watch the first pouch change being undertaken by the 44 october 17 :: vol 22 no 6 :: 2007

3 nurse. Most patients, especially if well prepared before surgery, will begin hands-on participation at the second pouch change procedure. Barring any unforeseen problems, the patient may be completely self-caring in five to ten days post-operatively. It is often suitable at the end of each meeting to set goals for the patient to aim for at the next teaching session. These should be reiterated at the start of the pouch change procedure to clarify them and allow the patient to question or discuss his or her feelings about the goals. It may, on occasion, be necessary to alter the goals slightly at each sitting to gain the co-operation of the patient and increase his or her confidence. By encouraging the patient to undertake more steps at each session he or she should be able to complete the whole pouch change procedure before discharge. It also encourages the patient to work in a methodical manner, preparing everything before changing the pouch. It is essential that all equipment is prepared before undressing the patient. It is poor practice to prepare the patient and then leave him or her partially uncovered to prepare the equipment. This can also help to prevent accidents as an unpredictable stoma may act while the old pouch is off and the equipment is being prepared. Equipment Basic equipment is needed for all pouch change procedures, irrespective of type of stoma. Certain specific equipment, such as skin preparations for excoriated skin or fillers for skin creases to prevent leakages, may also be required. It is essential that the nurse undertaking the teaching session is aware of any potential or actual problems faced by the individual and, therefore, the relevant care plan, medical or nursing notes should be accessed before beginning. The equipment required for a non-problematic stoma for a patient in hospital is listed in Box 2. For a patient in the community who is self-caring not all of this equipment is necessary. The procedure This procedure was developed from chapter 15 in The Royal Marsden Hospital Manual of Clinical Nursing Procedures (Baxter and Lloyd 2004) and local procedures at the author s NHS hospital trust. They may need to be adapted to comply with the reader s trust policies and procedures (Box 3). Rationale and evidence base The rationale for undertaking the steps outlined in Box 3 in a logical order is to ensure that the procedure is carried out safely and in such a manner that the patient can understand all the steps to enable him or her to perform self-care. BOX 2 Equipment needed for pouch change procedure Warm tap water. Disposable cloths for cleaning the stoma. Disposal bag. Jug to empty the appliance, if necessary. Gloves for the nurse. Apron for the nurse. New appliance. Template to ensure correct aperture of new appliance. Soap if desired, but this is not always required because clean water will suffice to clean the stoma. Scissors to cut the pouch if required, although some pouches are pre-cut. A pen to draw around the template if cutting the pouch to size. The first stage is to explain the procedure and discuss the goals set. This will not only ensure the patient understands the procedure, has the opportunity to ask questions and consents to the procedure being performed, but also encourages him or her to take part in the pouch change procedure. The benefits of this are that it allows a degree of independence and helps to reduce stress by addressing physical and psychological needs (Beddows 1997). By ensuring the area in which the pouch change is to be performed is private and warm, the patient is able to feel more secure at a time that can be stressful for him or her. Patients with a stoma may experience problems including peristomal skin disorders (Bourgois et al 2001, Burch 2004) and this might be related to adhesive type. It is therefore important to assess the known sensitivities of all patients. For the purpose of stoma care, the main reaction is likely to be to the latex gloves worn by the healthcare professional undertaking the teaching session. It may become apparent in later pouch changes that the patient has a reaction to an individual product or accessory used and the knowledge and skills of the specialist stoma care nurse should be sought in this instance. Allergic reactions to the stoma pouch may become apparent early on, but some patients develop allergies later in life and the reason for this is unknown. The use of a protective pad helps to avoid unnecessary distress for the patient if the unpredictable new stoma should act during the procedure, although many patients dispense with this later on. It should be explained that this is natural and that patients have no control over the timing of the stoma function, thereby reassuring them that it is not their fault. They should be reassured that some patients, but not all, find their stoma settles into a routine. Therefore, they october 17 :: vol 22 no 6 ::

4 will become aware of the best time to change the pouch. This is more common for a patient with a colostomy but some patients with ileostomies, and even urostomies, find there is a quieter time during the day when they may be able to change the pouch with more confidence that it will not act. Instructions on how to remove the appliance without causing trauma to an already tender area of the abdomen are of great importance, not only to reduce trauma but also to promote patient comfort. It is advised that, if possible, the patient supports the skin with one hand while slowly peeling the adhesive away with the other. This BOX 3 Teaching a patient the pouch change procedure used in stoma care Action Explain and discuss the procedure with the patient. Assess competency and set new goals. Check for allergies, for example, latex. Prepare the area for the procedure to be performed and ensure the patient is in a comfortable position to watch or perform the procedure. Prepare all necessary equipment. Use an absorbent towel or pad to protect the patient s clothing from stomal output. The nurse undertaking the procedure needs to wear an apron and gloves. Ensure both the patient and nurse wash their hands before and after the procedure. Empty the pouch into a jug if drainable. Remove the pouch gently by pulling with one hand while holding the skin taut with the other hand. This may need adapting if the patient has the use of only one hand. Place the used appliance into the disposal bag. Clean the peristomal skin (skin surrounding the stoma) using disposable cloths and water. Soap, which should be mild and not perfumed, can be used if wished. Ensure the surrounding skin is thoroughly dry before applying the new appliance. Assess the stoma and peristomal area for variances from the norm. Check fit of current template and alter as necessary. Approximately 1-2mm of skin should be visible around the stoma when the pouch is fitted correctly. Apply the new pouch by removing the protective backing paper and apply the pouch carefully over the stoma, ensuring the stoma is sited within the centre of the aperture. Dispose of all waste in line with the trust s procedure for the disposal of clinical waste. Explain to the patient the procedure for disposal in the community, that is, the disposable bag containing the waste should be tied in a plastic bag and disposed of in the rubbish bin. The content of the used pouch should be disposed of in the toilet by cutting the bottom of the pouch for a closed pouch before disposing of the pouch in the domestic rubbish bin. There may also be a clinical waste collection facility but information about this should be obtained from each trust s stoma care specialist. The nurse and the patient should wash their hands thoroughly using antibacterial soap or handrub. Rationale (Adapted from Baxter and Lloyd 2004 and University Hospital of North Staffordshire NHS Trust 2007) To ensure the patient understands the procedure and to familiarise him or her with the equipment and procedure to be undertaken. Obtain valid consent and identify what stage of competency the patient is at. To ensure patient safety and prevent allergic reactions. To ensure privacy and ensure the patient is comfortable and secure. To ensure the patient understands the need for preparation before beginning the procedure. Avoid the necessity for changing clothes after the procedure and to help prevent the patient from becoming demoralised due to soiling. To demonstrate the procedure for emptying the pouch and for ease of handling the appliance on removal to prevent spillage. To reduce trauma to the peristomal skin. To ensure correct disposal of clinical waste. To ensure the stoma and surrounding skin are clean and dry. To ensure all actual and potential problems are identified early and reported to the stoma care nurse specialist and medical staff. To enable early treatment to be started. To ensure a correctly fitted appliance which can prevent skin excoriation due to an ill-fitting pouch. To ensure correct disposal of excreted body fluids to reduce the risk of contamination and cross-infection. To prevent cross-infection. 46 october 17 :: vol 22 no 6 :: 2007

5 may need to be adapted for patients with dexterity or arm mobility problems. A small amount of skin irritation is usual under an appliance. However, this can settle quickly and this should be explained to the patient to avoid undue distress. Some patients may also be ticklish and wish to remove the pouch themselves on the first pouch change. These patients should be encouraged to do so but using the technique explained. The procedure for disposing of the pouch should be explained to the patient. While in hospital it is the nurse s responsibility to ensure the patient is aware of the need to dispose of all clinical waste appropriately. However, it should be explained that, when at home, it is acceptable to dispose of used stoma care equipment in the domestic rubbish bin, with many patients preferring to empty the pouch and double wrap it in disposal bags. This is to ensure that all clinical waste is disposed of in such a manner as to reduce the risk of cross-infection. Cleaning the stoma and surrounding skin ensures that the stoma and peristomal skin are kept clean, which reduces the risk of skin excoriation. During each pouch change careful observation and assessment of skin and stomal condition should be undertaken and any variance from the norm should be reported to the specialist stoma care nurse and medical staff. This enables the most appropriate treatment to be instigated at the earliest opportunity. The size of the template and the positioning of the pouch are important to prevent an ill-fitting pouch and any problems that can be associated with it. If the template is too large it will lead to excoriation of the skin, potential pouch leakage due to poor adherence and associated pain and distress for the patient. A template that is too small causes leakage from the pouch and potential trauma to the stoma. The need for a correct fitting pouch should be explained to patients and they should be shown how to measure the stoma size, using the template guides supplied with the pouches, on a regular basis. If they are uncertain when the need for a new template arises they should be encouraged to seek advice from the stoma care team in the outpatient clinic. The nurse and the patient should wash their hands thoroughly, or use an alcohol hand rub, to ensure the risk of crossinfection is minimised. Conclusion There is a need for careful psychological preparation and physical assessment of patients before stoma-forming surgery. Psychological preparation aids recovery by reducing anxiety and it improves the individual s capacity for learning self-care skills. This article provides information on the skills and steps required to enable ward-based nurses to become actively involved in teaching new patients to change a stoma pouch. The successful outcome of all counselling and stoma care teaching, for patients, their families and the healthcare professional, is to teach self-care and instil confidence in patients so that they can effectively manage their own care in the community NS References Baxter A, Lloyd PA (2004) Elimination: stoma care. In Dougherty L, Lister S (Eds) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Sixth edition. Blackwell Publishing, London, Beddows J (1997) Alleviating pre-operative anxiety in patients: a study. Nursing Standard. 11, 37, Bekkers MJ, van Knippenberg FC, van den Borne HW, Poen H, Bergsma J, van BergeHenegouwen GP (1995) Psychosocial adaption to stoma surgery: a review. Journal of Behavioral Medicine. 18, 1, Black P (2000) Practical stoma Care. Nursing Standard. 14, 41, Boore JRP (1978) Prescription for Recovery: The Effect of Pre-operative Preparation of Surgical Patients on Post-operative Stress, Recovery and Infection. Royal College of Nursing, London. 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