All Things Ostomy

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• Speaker:Joanna Burgess, BSN, RN, CWOCN

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Resources:

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The information and services provided by Fight Colorectal Cancer are for general informational purposes only. The information and services are not intended to be substitutes for professional medical advice, diagnoses or treatment.

If you are ill, or suspect that you are ill, see a doctor immediately. In an emergency, call 911 or go to the nearest emergency room.

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Speaker:Joanna Burgess, BSN, RN, CWOCN is a full scope practicing WOCN working for WakeMed Health and Hospitals in Cary, North Carolina.  Her passion for ostomy care stems from her 51-year journey of living with an ostomy since age 3.  Joanna was the 2011 National Great Comebacks recipient and has shared her story on a state and national level.  She was named the 2016 WOCN of the year for the southeast region of the United States, and is honored to serve on the board of the United Ostomy Associations of America and chairs their advocacy committee.

Navigating the Ostomy ExperiencePresented in partnership with

Fight Colorectal Cancer and

The United Ostomy Associations of America Inc.

Joanna J. Burgess BSN, RN, CWOCNFebruary 14, 2017

Today’s Discussions

• Colorectal cancer

• Treatment

• Pre and post operative considerations for those facing ostomy surgery

• The lived experience

• Resources

• Q&A

The Faces of Ostomy Surgery

My Story

“There is a pivotal moment in everyone’s life when you are no longer heading in the same direction that you were only moments before”. Tiffany Christensen

Information was gathered from:

• My work as a WOCN in an acute care center.

• My work as an ostomy nurse in the outpatient clinic setting

• My participation with the national WOCN ostomy committee and WOCN Society.

• My participation in on-line and community ostomy support groups.

• My work as a national spokeswoman for people with ostomies through the Great Comebacks program.

Focusing on Colorectal Cancer

Colorectal cancer (CRC) is the third most common cancer diagnosis among men and women combined in the United States.

Colorectal Adenocarcinoma accounts for the majority of cancers in the colon and rectum.

The GI System

Large Intestine (Colon)

The lowest part of the digestive system. Water and salts from solid waste are

extracted before waste moves through the rectum and exits the body through the anus.

Small Intestine

Where approximately 90% of digestion and absorption of food occurs.

Surgical Management of CRC

Surgical resection (colectomy) – removal of part of the colon.

Anastomosis: The area where the two remaining ends of the colon are sewn or stapled together.

Surgical Indications for Rectal Cancer

Transanal Local Excision – For low grade, node negative tumors with a curative intent.

Low Anterior Resection (LAR) – For cancers in the upper and middle third of the rectum. Involves resection of the sigmoid colon and involved rectum – the distal rectum and sphincter are left intact.

Surgical Indications for Rectal Cancer

Abdominoperineal Resection (APR) – For low rectal cancers with sphincter involvement. Involves resection of the sigmoid colon, rectum and anus, and creation of a colostomy.

What is an Ostomy

Stoma: A surgically created opening in the abdomen. A portion of the intestine is brought through an opening made in the abdomen and sewn down to the skin.

End Stoma

Loop Stoma

Images courtesy of Hollister Incorporated, Libertyville, Illinois

Ostomy Types

Colostomy: An ostomy made from the large intestine

Ileostomy: An ostomy made from the small intestine (the ileum)

Reasons for an Ostomy with CRC

Temporary Ostomy - Provides a temporary diversion to protect the healing surgical site or to relieve the pressure in the colon from an obstructing tumor.

Permanent Ostomy – Created when reestablishment of intestinal continuity will not be achieved or the anal sphincter is resected.

Preparing for Ostomy SurgeryCommonly Asked Questions/Concerns

Will people accept me?

How will I manage my ostomy?

Will this surgery save my life and how will it change my life?

How will my family and friends react to my ostomy?

Concerns about hygiene

Concerns about intimate relationships

Be Informed

• Acknowledge/Find your support system

• Be proactive in understanding the kind of surgery you are having

• Visit with a Wound Ostomy and Continence Nurse (WOCN)

• Visit with a UOAA member who can reinforce information given by the surgeon and provide real-life experiences of patients with a stoma.

What to Expect the Days Prior to Surgery

Meet with WOCN

• Basic review of ostomy care

• Introduction to the pouching system

(Causes loss of ability to control elimination of stool and gas)

• Answer questions – the basics of living with an ostomy

• Stoma site marking!

Pre-operative ConsiderationsStoma Site Marking

It has been shown that pre-operative stoma site marking by a WOCN greatly improves the quality of life for the patient.

It takes a team effort (surgeon, patient, WOCN)

Colostomy – Left Abdomen

Ileostomy – Right Abdomen

What patients said who had pre-operative counseling

Patients who received pre-operative teaching and stoma site marking were very grateful for the time that was spent with them.

“I had time to ask questions and participate in decision making.”

“I felt more confident going into surgery after spending time with my WOC nurse.”

“I liked knowing that she was thinking about me during my surgery and that she would be there after surgery.”

Post Operative Considerations

• Ongoing assessment by nursing of the stoma

• Ongoing assessment by nursing of stoma output

• Stoma may or may not have a catheter

• Pouching system will be clear

Considerations with a Colostomy

• Edema of the stoma – stoma will shrink for the next six to eight weeks

• Ileus is normal for first several days post op (24-72 hours)

• Stoma output will start as liquid, then will be mushy until eventually formed

• May need to lubricate the pouch

• Stoma Irrigation (for those facing a permanent colostomy)

Colostomy Irrigation has been shown to increase quality of life

Images courtesy of Hollister Incorporated, Libertyville, Illinois

Dietary Modification is not usually necessary – nutritional absorption is usually not affected.

Post operative:

• Chew foods well and consider eating small frequent meals

• Certain foods may cause excessive gas and odor – a low residue diet is best right after surgery.

• After surgery avoid carbonated beverages, sipping through a straw and gas producing foods.

Diet Considerations/Colostomy

Considerations with an Ileostomy

• Edema of the stoma and presence of loop catheter

• Bowel function: stool produced 12-24 hours post- op, color will be dark green, viscous and odorless

• Initially will have high volume of liquid output (>1000 cc/day). Bowel will gradually adapt

• Accurate I&O’s crucial

• High risk for peristomal skin breakdown

Special Considerations - Ileostomy

• Will need 10-12 glasses of fluid each day

• Medication concerns: large pills, enteric coated pills, sustained-release medications.

• Never give a laxative!!!!!!

• Inform your MD and Pharmacist

Diet Considerations/Ileostomy• Consider eating small frequent meals and maintain adequate fluid intake during the immediate post

op phase.

• Chew foods well to optimize digestion and absorption

• Monitor stoma output. Prevention of fluid and electrolyte imbalance is important.

• If >1200 mls output in 24 hours notify MD

• Foods to thicken stool: bananas, rice, applesauce, peanut butter, crackers, pasta bread, marshmallows, cheese.

• Some high fiber foods may cause a stoma blockage: apples, celery, corn, raw cabbage, dried fruits, nuts, meats with casings, mushrooms, coconut, foods with large seeds.

Check Off List Prior to Discharge • Learn how to empty the Pouch

• Learn how to change the pouching system

• Learn how to trouble shoot any difficult issues

• Learn your Nutritional guidelines

• Learn how to order supplies

• Learn what the resources are in your community (ostomy support group,

• outpatient ostomy clinic)

Living with an Ostomy

Basic Pouching Systems:

One piece Two piece – Wafer/Barrier and pouch

Images courtesy of Hollister Incorporated, Libertyville, Illinois

Accessory Products – Images courtesy of Hollister Inc.

Ostomy pasteOstomy Powder Ostomy Belt

Adhesive Remover Moldable ring Skin Protectant

Paste Strips

The Top Five Issues Patients Face at Home

Peristomal skin irritation 76%

Pouch leakage 62%

Odor 59%

Reduction in Previously enjoyed activities 54%

Depression and Anxiety 53%

Richbourg, L et al (2007) Difficulties Experienced by the Ostomate After Hospital Discharge. Journal of Wound, Ostomy, Continence Nursing. 34:70-79

Problems That Should Be Reported• Inability to maintain a pouch seal

• Skin issues that won’t heal after 1-2 pouch changes

• Separation of the stoma from the peristomal skin

• Changes in color of the stoma (should remain beefy red in color)

• Changes in appearance or length of the stoma

• Prolonged abdominal pain/persistent nausea or vomiting

• Changes in output (2 days for colostomy, 8 or more hours for ileostomy)

Phases of Recovery

Shock/Disbelief and panic

Defensive Retreat (Denial)

Acknowledgement

Adaptation or Reconstruction

Trauma is more about the future

than it is about the past.

What I Wish I Had Known Voices from Ostomates

• Don’t sugarcoat

• Be as realistic as you can

• You are not alone

• Provide compassionate honesty

Ostomate Bill of RightsThe Ostomate shall:

Be given pre-operative counseling Be informed of Community Resources

Have an appropriate positioned stoma site Have post operative follow-up and lifelong supervision

Have a well-constructed stoma Benefit from team efforts of health care professionals

Have skilled postoperative nursing care Be provided with information and counsel from the UOAA

Have emotional support

Have individual instruction

Be informed of the ability of supplies

Considerations Post Ostomy ReversalInterrupting bowel function with a temporary ileostomy increases the likelihood that patients will

experience alterations in bowel function after surgery.

Symptoms: rectal urgency, frequency, fragmentation of stool, incontinence.

Treatments are behavioral strategies based on symptoms:

Dietary modification Pelvic Muscle Retraining (PMR)

Incontinence pads Pharmacotherapy (loperamide, codeine)

Skin care Biofeedback

Concerns for Women

Some women may experience sexual dysfunction post ostomy reversal or post permanent colostomy/Ileostomy due to narrowing of the vagina (stenosis).

Concerns should be made to the surgeon/MD for referral to a GYN. This can be remedied through a series of vaginal dilatation procedures.

Symptoms:

Painful intercourse

Inability to have intercourse

For Those Facing a Permanent Ostomy

Diet

Activities

Coping

Telling Others

Intimacy

The Lived Experience – Karen Lewis

Ulcerative Colitis/Colorectal Cancer/Ileostomy

The Lived Experience – Randy HennigerPatient Advocate/Surfer

Colorectal cancer stage III - Colostomy Activeostomates.com

The Lived Experience – Colonel Justin BlumPatient Advocate

Ulcerative Colitis, Colon Cancer, Ileostomy

Ostomy Companies

www.hollister.cm - Hollister

www.convatec.com- Convatec

www.coloplast.com – Coloplast

www.marlenmfg.com - Marlen

www.nu-hope.com – Nu-hope

Ask for their support care services

 

Resources

www.cancer.org - The American Cancer Society

www.wocn.org – Wound, Ostomy and Continence Nurses Society

www.inspire.com – Hosts an online support group for patients with ostomies

www.colontown.org – Colontown an online ostomy support group

www.veganostomy.ca – Vegan Ostomy

Thank you and Questions!

Question & Answer:

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