Ideally, a person undergoing an ostomy surgery will first see an Ostomy Nurse (ET) to receive instructions on how an ostomy functions and how it is managed. Usually after teaching or another time before the surgery, an ET Nurse will mark the surgery site for the ostomy. Occasionally, an ostomy surgery is performed as an emergency procedure and the patient may not have time to consult an ET Nurse before the surgery. In this situation the surgeon will mark the site in the operating room. In both cases the patient will receive post-operative education by healthcare staff (ideally, by an ET Nurse). In an emergency situation, this step can be challenging for someone learning to manage their ostomy in a hospital environment, as they are also dealing with pain, nausea, fatigue, lack of sleep, and other issues. When the surgery was done as an emergency this can be emotionally difficult without pre-operative education and general preparation. Patients may forget some information and feel unprepared by the time they’re discharged. ET Nurses try to minimize these difficulties by providing educational materials and follow up support.
A recent ostomy patient should follow up with their family doctor, usually within a week or two of being discharge from the hospital. Some surgeries for cancer, Crohn’s, and diverticulitis may or may not require the creation of an ostomy, while an ileostomy is almost always required for a person with Ulcerative Colitis. Some family doctor’s may or may not be familiar with ostomies, so it is important for the patient to be well informed when discussing medical concerns that may or may not relate to their ostomy. Some issues apply to all ostomies while others will apply to the type of ostomy a person has.
A recent ostomate should generally limit lifting or straining to around 10 pounds for the first couple of months following surgery. Lifting weight beyond this amount may place a person at risk of developing a parastomal hernia (a type of incisional hernia that allows profusion of abdominal contents through the abdominal wall defect created during ostomy formation). The chance of developing a parastomal hernia is around 37% but may be higher based on contributing factors such as age, gender, weight and type of ostomy.
The skin around the stoma is another area a new ostomate should be cautious of. Denudation or loss of the surface layer of skin around the stoma can occur with all stomas. This is more common with ileostomy patients due to the alkaline composition of the stool coming into contact with the appliance. Treatments with ostomy powder and skin sealant are the most common remedies for this condition. After some time has passed from the surgery date a patient may need to reassess their pouching requirements and practices.
Cellulitis or fungal infections may occur under the pouching system. Some people with an autoimmune condition, such as inflammatory bowel disease or rheumatoid arthritis, may develop a skin condition called Pyoderma Gangrenosum. For this, and other atypical Continue On Next Page...
skin conditions, a dermatologist should be consulted. An ET Nurse can work with a dermatologist to help a patient with this type of skin condition. It is common for doctors to prescribe a topical ointment or cream (anti-fungal, antibiotic, cortisone etc.) to be applied to the affected skin. This practice is not recommended as these products can interfere with the appliance sticking to the skin and cause it to fall off.
Patients can consult with their doctor regarding non-medical issues, such as travelling. Unless there is a separate medical concern, there should not be any restrictions to travel, related to having an ostomy. Also, a doctor’s note is never required for any type of activity for those living with an ostomy. If a device such as a belt or stoma protector is needed for some activities such as sports or work an ET Nurse can assist in finding the appropriate product.
Ileostomy patients often have more management concerns than other types of ostomates. If a patient is already on medication or they’re going to be prescribed medication, it is important that correct type is ordered. For example, pills that are enteric coated, sustained release, or extended release may not be properly absorbed and may pass into the pouch. Very large pills, including over the counter medication and supplements, may not break down well and be absorbed. There’s also a possibility of blocking the stoma opening. It is helpful to clarify with the pharmacist if the type of medication prescribed will be appropriate. In relation to medication, a patient with an ileostomy should never be ordered laxatives or stool softeners. A person with an ileostomy can have a food or pill blockage but would not experience constipation. Such medications can cause watery stool that may lead to dehydration and electrolyte imbalance.
Another concern of an ileostomate is food and diet. While in the hospital most patients will be seen by a dietitian who will provide information on an ileostomy diet. Patients are advised to avoid hard-to-digest food like nuts, seeds, and foods with a higher amount of insoluble fiber, such as celery, popcorn and leafy greens. This is advisable for a period of around two months before gradually increasing the intake of harder-to-digest foods. These foods should be introduced back into the diet one at a time and in small amounts, around ¼ cup at time, chewed well with a half a cup or more of liquids. Intake is gradually increased. Also note foods that contain strong dyes like beet, certain spices, and sports drinks will dye the stool. There are typically no diet modification for persons with a urostomy or colostomy.
Urostomates should expect urine to look clear and may contain shreds of translucent or white mucous. This is normal as the stoma is part of the portion of the small bowel used to create the conduit (or loop) that drains urine from the kidneys by way of the ureters. The conduit naturally produces mucous that will drain into the pouch. This does not mean there is an infection present. If the urine that is cloudy and foul smelling may indicate a urinary tract infection. Fever, nausea, fatigue and flank pain may also be present. A doctor may order a sterile urine specimen be taken from the pouch to determine if infection is present. The preferred method to collect a sterile specimen requires the removal of the pouch, cleaning the stoma and inserting a short catheter into the stoma to drain urine into a sterile container. This is typically done by an ET Nurse.
Lastly, one of the more common issues for a person with a colostomy is constipation. Unlike an ileostomy a person with a colostomy can become constipated. A doctor may prescribe a laxative or stool softener but this should only be taken orally. Suppositories or other medications that would normally be inserted through the anus are not recommended. This is because there is no sphincter in the stoma to help keep the medication in place until it is Continue On Next Page...
absorbed and it will therefore come out.
For any ostomy related issues ET Nurses often collaborate with doctors and other healthcare professionals to help promote adjustment to living with an ostomy and other related concerns that may come up in the future. If you have any questions or need assistance in working with your doctor contact your ET Nurse. ■
By Neal Dunwoody RN, ET
Neal Dunwoody is a Registered Nurse with over nine years of experience in wound, ostomy and continence care. He completed his WOCN designation through Emory University in Atlanta, Georgia in 2006. In 2008, Neal moved to St. Paul’s Hospital to take up the position of clinical educator for Enterostomal Therapy where he continues to work today. Outside of St. Paul’s, Neal schedules regular ET appointments through Nightingale Medical’s West Broadway location.