"Pre & Post-Operative Ostomy Care" presented by Alexis Sherman, RN, BSN, CWOCN
A virtual course series created by Dr. Jean-Frederic Colombel and his team to provide medical education on IBD management to IBD physicians practicing in Ukraine, addressing the lack of educational opportunities available as a result of the war.
Chapters (Click to go to chapter start)
Ileostomy vs. Colostomy Stoma Site Marking and Placement Post-Op Stoma Complications Peristomal Problems Goals for Ostomates Most Common Patient Concerns Resources Hi there, my name is lexie Sherman. I'm a wound continence nurse um at Mount Sinai hospital and I'm gonna just give a little talk on pre and postoperative Ostuni care. Um Just some brief overview and then discuss a little bit of the psychosocial concerns that um our patients come to us with. So I'll address some of the common perry como um complications and talk about um activities of daily living. So it's really hard to get um an exact number of how many Oscar means there are in the world. Actually the best numbers I was able to get through market research reports, it's about a $2.6 billion and they say in Europe there's about 750,000 estimates about a million in the United States. Um Overall colostomy. These are the most common, although at Mount Sinai um we see a lot more Elias Tommy's given that the majority of our patients are getting them from inflammatory bowel disease. Um But Worldwide it's about 43% colostomy, 41% Elias Tommy's and only about 18% your ost amis. Um So for the purpose of this lecture we'll just stick with the ficus temas. Um Typically Elias tummies are on the right side, output is liquid to pasty. It's never formed. The average person empties 4 to 6 times a day. Um And it's the most common type of soma. We see for ulcerative colitis and these patients are at much higher risk for dehydration since the colon is not being used and we tell our patients that they cannot take any slow release or enteric coated medications. Um Often times you'll just see them whole in the pouch closed involuntary bowel disease, most often on the left side, output varies depending on what part of the colon. Usually they're kind of a sigmoid um colostomy and the stool is very formed. Oftentimes um they'll go back to their frequency of stool wings with the land one stool a day. That is what they'll go back to. And patients with colostomy is can actually learn to irrigate so that they do not need to wear a pouch. Um And oftentimes with colostomy is they'll use a closed end pouch, just dispose of it every day and snap on anyone. So to me the most important role of an Oscar winners. And I think what for gastroenterologists is to stress that any patient that they anticipate could or may end up with this toma. Um have them pre op marked by an Austrian erste if you have one available. Um It really is the gold standard to ensure the improvement in quality of life. Um We, as Ostuni nurses will assess the patient. I mean I've even gone into the pack, you pre op area. Um Just any chance we can to mark before surgery, ideally we would like it a few days ahead of time. So we can do some pre op education as well, but to just get marks on the belly is really critical. So we assess the abdomen in multiple positions with people sitting and standing, um we take into consideration the type of surgery someone is undergoing. I'm looking for a nice flat patching surface within the patient's visual fields that they can be independent in their care. I want it within the rectus muscle to decrease risk of hernia away from the umbilicus because that tends to cause a lot of creasing unfolds and away from any brahmanic prominence is um where a lot of pressure ulcers can actually develop from appliances. I also consider someone who's wheelchair bound. I'll probably mark them higher women during pregnancy if the storm is going to be temporary, let's say they're flaring during pregnancy, most likely will be reversed afterwards. I will mark them much higher up so that they can be independent throughout their pregnancy. If it's more of a long term, even post um delivery, I would probably consider marking them lower just to make it easier for them long term with clothing and um such. I also do consider some occupation of my patients, particularly like police officers who have to wear a holster. I don't want their their snowmen at the belt line. So I want to take those kinds of things into consideration. Um This is just an example of why it's so important flying down this patient looks like he, I can put his name up pretty much anywhere. Um He does this, it's a little trickier when someone already has a site and he's being recited and I have to find a new location. But when you sit this patient up a lot of his sights pretty much disappear. Um So then this is what happens sometimes in the operating room. Um Here's some more examples of Belize. The two on the middle and on the left is sitting and standing of the same abdomen. The one on the right just shows you kinds of things that we have to take into consideration. She has a lot of scarring and old storm a site um officials to and all the little criteria that all those little creases and intense become leak tunnels and make patching very difficult. This is an abdomen that unfortunately was not marked. And you can see how you can't even really tell where the stoma is happens to be right in there. Um And it was in such a poor spot that it actually were attracted. And to most um Here's another example. This one should have been um lower down and um it really doesn't pack quality of life. It's a lot more expensive in terms of supplies. They have to use a lot more specialized equipment, increased frequency. Um They may not be able to obtain the supplies that are really required and takes a lot more effort to put on these pouches. Plus all the issues with skin irritation and stuff from a poorly sighted soma. So if at all possible um sort of encouraged surgeons even having the surgeons look at the belly at a time instead of when the patient's flat on the operating room table. So I'm gonna go into some post op complications. So this toma on the left is the one that we all wish every patient had nice well budded perfectly round and this is an end soma but it looks great away from blake is away from the scars, Nice flat patching surface. Um These are more media post op complications. The stone in the middle is a democratic soma. When we see this dark cherry red to black, um what we do is take a like test tube and put it through the stomach to look at the inside of the fashion. If below the fashion, it's fine. Then we leave them alone. The stone itself at the outside will kind of slough off and it'll usually stenosis, but they don't have to go back to the operating room. Obviously if it's necrotic under the fashion, it's urgent and they need to go back and be revised the storm, always the right we see often in our IBD patients who have been on chronic steroids where uh skin separates. Um and it looks awful. But um it just takes time. We teach the patients how to fill in that area with stone powder and usually hydro fiber or an algae innate dressing to create a flat surface. Um and it will fill in over time. It's just um We want to avoid um products like a convex appliance that we often use to help. We do tend to avoid those right now with this issue. So one of the more common, more immediate post op issues. Still more retraction. We see it a lot with obesity and pregnancy um when the surgeons are actually unable to mobilize the bowel well and it creates these retracted sistemas. Again it these aren't preventable usually, but it's costly. A lot of challenges for patients in terms of patching um The bag you see there is one that we really like to use. It's very flexible. Um And it can help address these retracted cinemas. And we often use a belt with this. Um These are some examples of stone optics comas can happen more immediately or long term um Often just at the skin level but can cause um obstructions. And the patients have to go in for dil ations a lot. Um Not much you can do in terms of patching the um stone is often have to be revised um paris normal hernias most common um with colostomy. Um And also with patients who weren't marked. So the storm is not within the rectus. Um We often times they're left alone, but we do educate the patients on signs and symptoms of obstruction. Um And we can fit them with specialized belts um that we measure the size of the hernia. And use the type of patching they're using to decide what size belt they need. Um It's very these belts are really helpful. They also have um modifications for concern for prolapse. Um The one on contraindications with patients with is um irrigation for colostomy. And with hernias. We also want to avoid convex barriers because they can cause a lot of pressure as well. So we avoid that. You can kind of see at the bottom between five and six o'clock there's some pressure starting on that hernia from the appliance. So prolapse can happen at any time throughout the course of the most common with colostomy. The stomach on the top is a loop. So you actually see both ends of the um loop uh prolapsed out. Um The stomach on the right is become below is becoming a ischemic from the prolapse. Oftentimes they can be reduced um We still use sugar sometimes in the E. R. S. Pour it on this noma to help um reduce them. And um but oftentimes we just teach the patients to monitor them for signs of ischemia or obstruction and two awesome monitor the storm A. It's not uncommon especially patients wearing a two piece appliance that has the rigid ring at the bottom for the bag to attach to the flange to get um like uh breakdown on the stoma itself. And because there's no feelings there. They don't notice it but you can get quite a lot of injury. So um we usually recommend a one piece appliance that's very flexible and doesn't cause the trauma to this toma, but like a prolapse like the one on the top. Um Those can really only be managed using Fishel pouches. There are no appliances large enough and typically those have to be revised surgically. Now I'll just address some of the common paris normal issues. Um And when we see these in our clinic, what we want to do is we want to figure out what's causing it um modify the system and use different products. The picture on the top is follicle itis inflammation of the hair follicles very common with the trauma from removing an appliance. So we recommend adhesive removers to gently remove an appliance. We also teach our patients to shave the perry stone skin. People with chronic follicle itis often recommend um laser hair removal to um minimize that trauma. Fungal rashes are probably the most common. 2nd most common rash that we see, particularly in the warmer months. Um the moisture oftentimes from the bag. The plastics on the pouches themselves cause a lot of uh fungal rash. And we teach you can use any kind of uh antifungal powder, nice statin or Mykonos all powder Um Sprinkle that on the skin and then seal it with a barrier film. We don't recommend um using this long term but 3-4 changes using antifungal powder usually resolves the issue and often if patients are having this reoccurring, they'll also recommend like a cotton pouch cover that can be removed and replaced so that this skin doesn't always have the contact of the different plastics. Um The most common signs of fungal rash that we see most common issue is actually just from leakage. Especially with our Elias. To me patients we don't really see it with colostomy. Um But the high acidic content in the Elias Tommy's causes denuded skin. Um can be I've had times where people thought it was um cellulitis because it can get really bad, but once you stop the leakage, correct the cause of why the appliances we can get a good seal. Um You'll be amazed at how quickly the skin will recover. We use um hydro collide type powder storminess of powder on the skin. Um and then seal it with a barrier film to multiple layers. Because if you just put powder on the skin, the appliance isn't gonna want to stick you do multiple layers. Um and then modify the vouching for. So like in this image, this storm was actually pretty flush. So we would probably use like convex appliance. Make this to put some pressure um to make the soma pop up and that should help address the leakage. It will ask our patients do you leak from the same spot every time if they're home and we're just trying to give them some advice have them sit up look for any dents or folds that we can use um strips or paste to help fill those areas in and address those leaks. Allergies are a little bit challenging. Um patients have a lot of allergies to different um adhesives. Um the to determine what the allergen is, it usually mirrors the rash. So in this example it's pretty right around the stoma and it's from this ring that you see here. Um so ideally what we'll do first is we would switch brands. Um The three most common companies in the United States are also the most common um supply companies in europe and they have quite a variety of appliances and different skin barriers. So usually even if one brand isn't working, we can try another one. Um We will also recommend the use of skin silence um and worse comes to worse. We'd recommend a non adhesive system but they're very big income for some and patients don't really like them, but if we're finding that they're allergic to pretty much everything. We have no options. There are newer appliances on the markets being created with ceremonies in them and they are being seem to create less skin irritation. So pay a derma, we see that when I was in um school emery, I'm still that probably would say two or three cases of pioneer in my career. But being at Mount Sinai with inflammatory bowel disease. I've seen lots and lots of cases. This is just one example um and this patient uh developed really severe pie a derma. Um We along with the surgeons and dermatology work together to address the issues. Um The challenge, the most challenging part about paris normal payload Irma I find is that the path urge e just changing the pouch itself creates the path energy. So we try and reduce pouch changes. However the chronic moisture um and drainage makes that very difficult. Um So um oftentimes it's systemic with anti TNF topical and injectable international steroids um topical powders that we can use um and then we'll use like a hydro fiber. Help address um the moisture and avoid convexity to eliminate. To kind of decrease the path energy. And this patient um is a kind of a progressive picture. She actually did have to um she ended up going to the O. R. And having her stone removed. So that's why the picture all the way to the right is just the scarring afterwards and that still took time to heal. And you can see that it was a full thickness wound by the nature of the scar. But the picture on in the middle is after about three weeks of anti TNF interregional injections and um topic als this is just another example of um some earlier PPG. And this one um is just uh on the right is just one after one injection she participation noticed some improvement and did not need to be revised. Um So when I see patients um Either pre op post op my goal for all my estimates is to have them resume normal as life as possible and be independent in self care ideally with appliances, we want a minimum of four days and we do not like them going more than seven, although I prefer that patients change their appliances about every five days. Um So it's important to ask them how often they are changing their pouch. Um And I want to know um is what is their awesome e not allowing them to do and please help me make decisions in terms of um appliance selection, I like to reinforce with patients that just because I fit you with one thing in the hospital doesn't mean you're stuck with it forever. It's about finding what works best for you. Um Patients with Elias Tommy's, particularly ones who've had multiple receptions need high output pouches at times. Um So those have spouted bags at the bottom that can be connected to bedside bags and patients aren't up all night emptying. Um As I discussed earlier colostomy is oftentimes people can use closed end bag and dispose of it. Um Other criteria that I think about when um determining what appliances best for my patient, as I think about their store Mazz, is it budded ideally, is it flush or is it retracted and they need some convexity? Um Do they have any creases or folds that need a more flexible pouch as opposed to one that's more rigid. Um How is my patients dexterity. Are they able to cut appliances on their own or should they have something that's Moldable? Um Are they able to, are they visually impaired? Can they do this independently? Um Nowadays they have a lot of appliances that even if a patient wants a two piece where they can change the bag separate from the base. Um They have ones that are adhesive based as opposed to um using like coupling systems. So if they or dexterity, we can still give them a two piece. So lots of criteria that I think about when deciding on an appliance. Um This is just a small selection of the tons of options that are available for patients. Um Just some basics with eating um With colostomy is we don't restrict anything. Um We do encourage fiber intake um and educate on over gas producing foods. Um. Elias Tommy's for the first eight weeks. We like low fiber diets, avoid raw fruits, vegetables. Um And we discussed the high risk for dehydration and increased need for fluid intake as well as need for salt. Then briefly the most common patient concerns. Um leakage. Obviously number one um patients not feeling confident about their appliance don't want to get out and live a normal life so we need to figure out why they're having leakage um odors should not, they patients should not smell their pouch unless they're going to the bathroom to empty. Um The appliances themselves are over proof. There are lots of deodorants available but I actually find um breath mints work really well so you can drop one in the appliance um once you empty and then the next time you empty it smells like breath mints. Um As opposed to school clothing they usually don't need a lot of modification for um Being intimate is fine. Um Sex is fine once okay by surgeon but we educate patients not to use their cinemas for sex. Um In terms of dating and disclosure it's all personal. No one needs to know you have an Oscar me unless you want to tell them um showering bathing. There are no restrictions same with swimming. Um There are more and more products out there and bathing suits that have been developed to help contain the appliance. Um And with travel I always recommend patients bring way more supplies than they ever think they need um And to bring some that um if they're already using planes that are pre cut to actually bring some okay that are cut to fit in case their stomach swells while they're traveling. And also in terms of security um With T. S. A. And um traveling the three D. Scanners. Usually patients are stopped there um asked never to expose their bag but to place their hand over where their appliance is and are swapped in case for placing explosives inside the bag. Um They can ask for private screening. Um But if you go through the regular metal detectors, most people are not stopped just because of their austin, these are just some resources available and that is all. Thank you so much lexi. Um Alex if we have time for one or two questions before the uh question and answer at the end, I don't know and then we have a shower. Yes. Um alexia, alexia, thank you very much. I can I can hear how hard this presentation is for you and I like while we're waiting for a question, I wanna appreciate the notice of like limitations of the everyday living activity as people with Soma have because like I did not appreciate it. How different can be a lifestyle for the person with stammel with the good education and good care. So I'm pretty sure this this will be especially useful and I will interpret that to Ukrainian and will share with the nurses over Ukraine. Okay thank you so much if you can stop sharing your screen, see and then. Okay and now where is? Yeah I think oh my gosh this is a problem. I have it somewhere you're right okay, just once ago now. Okay, okay I will share my screen in once again, nope. Just once ago I need to just once again Ash um maybe you can stand by introducing yourself, you could see me or Yeah