Chapter 6: Elimination
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Pre‐procedural assessment and care
Pre‐procedural care can be divided into two sections: physical and psychological.
Physical pre‐procedural care
Physical care consists of surgical preparation, which can be in the form of bowel preparation, where patients are required to take laxatives to cleanse their bowel prior to surgery. This arguably improves surgical visibility and prevents contamination. This depends on the surgeon's preference and needs to be checked with the patient's surgical team on admission.
Many hospitals now carry out enhanced recovery programmes for colorectal patients. These involve intensive preparation pre‐operatively, where selected patients are required to take nutritional drinks and are given a pre‐operative stoma pack to practice with a stoma model and pouches to develop their skills in changing a stoma bag. This improves recovery and management and consequently reduces the length of hospital stays.
Stoma siting is one of the most important elements of pre‐operative care (Leyk et al. [130]); the site of the stoma can have a huge impact on post‐operative quality of life. Appropriate siting of a stoma minimizes future difficulties such as the stoma interfering with clothes, or skin problems caused by leakage of the appliance (Cronin [55]). Stoma siting should be carried out by a nurse who has been deemed competent to do so. For patients undergoing total pelvic exenteration leading to two stomas, care should be taken with the siting of both stomas (Hardy and McPhail [95]).
The use of accessory items should be limited to those that are key in assisting with skin health, skin barrier adhesion or leakage prevention. They should be suitable for the patient's condition (Black [28]).
Patient assessment is necessary, taking into account:
- physical restrictions and disabilities
- psychological status
- visual impairment
- manual dexterity
- lifestyle
- occupation
- hobbies, leisure activities and sporting activities.
All these factors need to be carefully considered and discussed with the patient while siting the stoma. Patient involvement is important as it allows the patient control and enhances their ability to cope with a newly formed stoma.
Procedure guideline 6.25
Stoma siting
Psychological pre‐procedural care
Psychological preparation of individuals facing stoma surgery should begin as soon as surgery is considered, preferably by using the skills of a trained stoma care nurse. It is important that the information and discussions are tailored to the individual's needs, taking into account their level of anxiety and distress (Di Gesaro [67]).
It is important that patients meet all members of the multidisciplinary team who are involved in their care and that they fully understand the need for the stoma surgery. This needs to be explained in order to obtain informed consent. It is beneficial if the patient is met in pre‐assessment or at home prior to surgery to discuss the implications of stoma care and the patient's own role in rehabilitation. At this point it is also helpful to provide the patient with written information, audio‐visual information (if available), access to self‐help support groups, and access to peer support including the chance to speak or meet with an experienced ostomate.
Stoma counselling is ideally carried out by the specialist stoma care nurse involved in the patient's care, but all nurses involved in the care of patients undergoing a stoma should be aware of the impact of having a stoma on:
- body image
- family relationships
- sexual relationships
- depression and anger
- fears and concerns.
It is often beneficial to provide patients with some patient information or literature to take home. This gives them an opportunity to digest the information and write down any questions that they have. There are many different aids available, such as information booklets, samples of various products, diagrams, audio‐visual information, stoma pre‐operative packs and websites. These help to reinforce and clarify the verbal information given to the patient.
Specific patient preparation
Education
Patients undergoing stoma formation have to make major physical and psychological adjustments following surgery. If the surgery is elective, patient education should begin in the pre‐operative period (Cronin [55], Wallace [240]). Adequate pre‐ and post‐operative support is mandatory to maintain quality of life for stoma patients (Metcalf [146]). Individual holistic patient assessment is key as it is important to identify appropriate teaching strategies for each patient. One of the most important ways in which a nurse can support the patient is to teach them stoma care, ensuring independence before discharge (ASCN [10], Burch [38]). It is important that the patient is able to independently change their stoma bag, recognize problems, and obtain support and supplies once they have been discharged home. Providing patients with adequate information and input helps to promote patient decision making by allowing them control (ASCN [10], Black [24]).
All healthcare professionals are required to wear disposable gloves and an apron when changing an appliance, and this practice should be explained to patients so that they do not feel it is just because they have a stoma that these precautions are being taken (Cronin [55]).
Procedure guideline 6.26
Stoma bag change
Procedure guideline 6.27
Obtaining a clean‐catch urine sample from an ileal conduit
Procedure guideline 6.28
