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Ostomy care

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Related Terms
  • Bladder, bladder cancer, bowel movement, colon, colostomy, constipation, Crohn's disease, diarrhea, digestive enzymes, enterostomal therapist, ET nurse, ileostomy, ostomy, ostomy pouch, peristomal skin care, permanent ostomy, rectum, small intestine, stoma, temporary ostomy, ulcerative colitis, ureters, urostomy, urostomy care.

Background
  • Sometimes treating diseases of the digestive or urinary systems (such as Crohn's disease, ulcerative colitis, or bladder cancer), involves removing all or part of the small intestine, colon, rectum, or bladder. In these cases, there must be a new way for wastes to leave the body. The surgery to create the new opening in the abdomen is called ostomy. An ostomy connects either the small or the large intestine to the surface of the body. The opening is called a stoma.
  • There are many different types of ostomy. Some examples are ileostomy, colostomy, and urostomy.
  • Ileostomy: In an ileostomy, a surgeon removes the colon and rectum and attaches the bottom of the small intestine (ileum) to the stoma.
  • Colostomy: In a colostomy, a surgeon removes the rectum and attaches the colon to the stoma.
  • Urostomy: In a urostomy, a surgeon attaches ureters (the tubes that carry urine to the bladder) to either the small intestine or to the abdominal wall.
  • An ostomy may be temporary or permanent. A temporary ostomy may be required if the intestinal tract cannot be properly prepared for surgery because of blockage by disease or scar tissue. A temporary ostomy may also be created to allow a disease process or operative site to heal without irritation by the passage of stool. Temporary ostomies can usually be reversed with minimal or no loss of intestinal function.
  • A permanent ostomy may be required when disease, or its treatment, impairs normal intestinal function, or when the muscles that control the rectum do not work properly or require removal. The most common causes of these conditions are low rectal cancer and inflammatory bowel disease.
  • Once an ostomy has been created, a surgeon or an enterostomal therapist or "ET nurse" (a nurse who specializes in ostomy care) will teach the individual to apply and wear a pouch called an ostomy appliance. The pouch is made of a special form of plastic that is held to the body with an adhesive skin barrier. Many sizes and styles of ostomy pouches are available. The pouch is disposable and is emptied or changed as needed. The system is quite secure; accidents (bladder or bowel spilage) are not common, and the pouches are odor-free. The frequency of bowel movements will vary, depending on the type of ostomy, the diet, and bowel habits prior to surgery. If the ostomy is a colostomy, irrigation techniques may be learned that allow for increased control over the timing of bowel movements.
  • Individuals with ostomies can lead normal lives. Someone with an ostomy generally cannot be outwardly distinguished from those who do not. Public figures, prominent entertainers, and even professional athletes have ostomies that do not significantly limit their activities. All usual activities, including active sports, may be resumed once healing from surgery is complete.

Complications
  • Surgical complications: There is a risk for complications during ostomy procedures. Complications include adverse reactions to anesthesia, excessive bleeding, infection, and injury to surrounding organs. There is also a risk for complications that develop after ostomy surgery, including infection.
  • Sexual dysfunction: Most individuals with ostomies resume their usual sexual activity. In men, removal of the lower rectum for cancer may result in sexual dysfunction due to injury to nerves that pass close to the rectum. This is unrelated to the ostomy. Many individuals with ostomies worry about how their sexual partner will think of them because of their condition. Support groups are also available in many cities. If the surgical procedure will require removal of the rectum, the individual may wish to discuss sexual function with the colon and rectal surgeon or an ET nurse prior to surgery.
  • Skin changes: Skin changes can occur in those with ostomies. The patient is usually the first to know that the skin has changed and has become irritated. If the pouch is leaking, the peristomal skin may be itching, burning, or painful.

Treatment
  • Ostomy surgery is a life-altering event; however, most are able to resume daily activities. After colostomy or ileostomy, individuals no longer have control over bowel movements, and after urostomy, individuals no longer control urination. Discharge from the stoma enters a pouch system.
  • Stoma care: After a procedure to create an ostomy, the stoma is shiny, wet, and red. It is usually round or oval, and gradually shrinks in size during the first few months. It is important that the pouch system fits correctly, so the stoma must be measured frequently, especially during the recovery period. The stoma may begin to close during the recovery period, so a correctly fitting pouch is important.
  • The stoma does not have nerve endings; therefore, it does not transmit sensations (such as pain). It is rich in blood vessels and may bleed slightly if rubbed or irritated. If bleeding is prolonged, or if the discharge from the stoma contains blood, pus, or a foul-smelling odor, a doctor should be notified.
  • Water cannot enter the stoma, so it is not necessary to cover it while bathing or showering.
  • Urostomy patients should test the pH level of their urine frequently and can usually maintain the proper level with diet adjustments. A healthcare professional can give advice on special dietary requirements. Urine that has a strong ammonia odor lacks acidity and may cause irritation and the formation of white, crystallized deposits around the stoma. These deposits can be removed using a solution of vinegar and water.
  • Peristomal skin care: Peristomal skin care is care of the skin surrounding the stoma (peristomal skin). This skin must be protected from irritating discharge. Discharge that is rich in digestive enzymes, such as from an ileostomy or an ascending colostomy, is particularly irritating to peristomal skin. Carefully cleaning and drying the skin with soap that is residue free, every time the pouch system is changed, is the best way to prevent skin irritation. Moisturizing soaps leave a residue that can interfere with the adhesion of the skin barrier of the pouch system. Residual free soaps can be found at a local health food store.
  • Peristomal skin infections can result from an increase in the normal fungi on the skin and the accumulation of moisture. Persistent irritation such as redness, rash, breakdown of the skin, and swelling should be reported to a doctor. Bacterial and yeast infections can occur.
  • It is also important to avoid the buildup of adhesive on the peristomal skin. The adhesives used to attach the pouching system are removed using gentle solutions that do not irritate the skin.
  • Pouch systems: While in the hospital, an enterostomal therapist or ET nurse will instruct ostomy patients how to change the pouch and care for the stoma and peristomal skin. Many individuals experiment with different types of pouch systems. There are many types of pouch systems, including Convatec's SUR-FIT Natura® two-piece system, Coloplast One-Piece Pouches®, and Hollister Pediatric Ostomy®.

Integrative therapies
  • Good scientific evidence:
  • Colonic irrigation/colon therapy: Irrigation of the colon for therapeutic purposes may have been used as early as ancient Egypt, China, India, and Greece. This practice gained popularity in 19th century European spas, and has been used in modern times to promote general well being and to treat multiple health conditions. Colonic irrigation may be used in patients with ostomies (post-surgical connections of the intestines to the side of the body). This procedure should be performed by or under strict supervision of a qualified ostomy healthcare provider.
  • Unclear or conflicting scientific evidence:
  • Cranberry: It is proposed that skin irritation at urostomy sites may be related to urine pH. Cranberry juice(Vaccinium myrtillus) can lower urine pH, and has been tested for this purpose. Further study is needed.
  • In theory, due to its acidic pH, cranberry juice may counteract antacids. Cranberry juice theoretically may increase the effects of antibiotics in the urinary tract and increase the excretion of some drugs in the urine. Cranberry juice may increase absorption of vitamin B12 in patients using proton pump inhibitors such as esomeprazole (Nexium®). Although controversial, some studies have shown that taking the prescription blood thinner warfarin (Coumadin®) and cranberry products at the same time can elevate the INR, which could increase the risk of bleeding.

Prevention
  • Living with an ostomy:
  • Individuals feel anxious, nervous, or scared when they first begin dealing with an ostomy. They find it unpleasant and sometimes feel they have lost control of their body. Such feelings do improve with time. Talking about them with a doctor, or someone close, will help the individual deal with issues related to ostomies and ostomy care.
  • Learning to live with an ostomy may be difficult for both the individual and their spouses. It is not good to ignore the problem, and discussion with family members is crucial.
  • If the individual had a happy sex life before ostomy surgery, sex life can be the same afterward. Close body contact cannot hurt a stoma; but emptying the pouch before having sex is important. Individuals may also want to wear a pouch cover.
  • After an ileostomy, the intestine has difficulty digesting high fiber foods such as corn, celery, apples, nuts, popcorn, or grapes. Healthcare professionals recommend that individuals not eat large amounts of these foods for several weeks after surgery. A doctor will advise the individual when they can begin eating foods with hulls, peels, or seeds. Then, eating small amounts at first to see how the intestine digests the fiber is recommended.
  • Because bowel movements leave the body sooner through an ileostomy, the intestines will not have a chance to absorb certain medications, including long acting or sustained release drugs. A doctor or pharmacist can recommend which medications are best to use with an ostomy.
  • Individuals should not use laxatives with an ileostomy because bowel movements will already be soft and semi-liquid. It is important to tell a doctor that an ileostomy is present so that they will not administer laxatives before a test or surgery.
  • It is important to drink enough to replace the liquid lost in the bowel movements. Drinking six to eight large glasses of water, juices, or other liquids each day is recommended by healthcare professionals. Or, if a fluid limit is imposed, follow a doctor's advice.
  • Maintaining a healthy diet that includes all five food groups: fruits, vegetables, breads, dairy products, meat, and fish. It is important to remember that eating certain foods, such as eggs, cabbage, onions, beer, and some cheese, may cause unpleasant gas. It is important not to eat too much or eat too fast, and to chew food well.
  • Pregnancy with an ostomy is possible. It may be advisable to wait a year or so after surgery to become pregnant so the body has a chance to heal and return to normal. A doctor can advise the woman about pregnancy with an ostomy.
  • Once the individual feels better after an ostomy placement, it is best to start an exercise program. Exercise helps heart health, lowers blood pressure, improves mood, and helps keep the individual healthy. Among the best activities for individuals with ostomies are walking, jogging, bicycling, and swimming. A doctor can help advise the individual on what exercises are best for them. When swimming, emptying the pouch before getting into the water is best. One can place waterproof tape over the edges of the device that secures the pouch.
  • It is recommended to always carry extra ostomy supplies and pouches when traveling.
  • There is no special diet required for individuals with a urostomy. Healthcare professionals recommend those with urostomies to eat a balanced diet and drink plenty of fluids. It is normally advisable to drink at least six to eight glasses of fluid (or 64 ounces) each day to avoid infections and keep urinary functions normal. Test strips can be purchased at a local pharmacy to test the urine pH.
  • Foods that can cause urine odor include asparagus, fish, and spices such as garlic.
  • Foods that combat urinary odors include: cranberry juice, yogurt, and buttermilk.
  • After ostomy surgery, digestion and absorption of medications, either alone or in combination, may be affected. It is very important to review medications, both over-the-counter and prescription drugs, with an ET nurse or healthcare provider.
  • Also, be aware that some medications can change the color of the urine. Individuals may wish to wear an opaque pouch in order to reduce visibility through clothing.

Author information
  • This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Care
  • There are many kinds of pouches for use with an ostomy. With time, individuals can decide what type works best. The individual will need to empty the pouch four to six times a day if they have an ileostomy, and one or more times a day if the individual has a colostomy. For both types, individuals need to change the pouch every four to six days, and clean it if it is reused. Individuals also have to care for the stoma and the skin around it. An enterostomal therapy nurse (ETN) or a doctor will instruct the individual how to care for the stoma and skin. Individuals may want to join a group that can offer them and their families support and information about ostomies.
  • Emptying the pouch: Healthcare professionals recommend to empty the pouch when it is a third to half full. The individual will probably need to empty the pouch four to six times a day.
  • It is best to sit on the toilet with the pouch hanging between the legs, or to sit on a chair next to the toilet with the pouch opening aimed into the toilet.
  • It is best to point the opening of the pouch into the toilet and remove the clamp that keeps the pouch closed. Slide the fingers down the outside of the pouch to squeeze the contents out of the pouch. Clean the inside of the pouch opening with a piece of rolled-up toilet paper.
  • After emptying the pouch, the individual may rinse it out with room-temperature water. To do this, use a rubber ear syringe to squirt water inside the pouch. Tip the pouch to get the water up into the top. It can be emptied and rinsed again.
  • The pouch can now be deodorized using specialized deodorants. The clamp can now be placed back onto the pouch to close it and the patient may wash their hands with soap and water. Gloves are also recommended by healthcare professionals.
  • Skin and pouch care: Ostomy pouches come in many styles: one-piece, two-piece, disposable, reusable, cut-to-fit, and pre-cut, for example. Some individuals prefer an opaque white or beige pouch to a clear one. An ETN or doctor can help the individual decide which type is best.
  • When changing the pouch, the stoma and the skin around it should be checked. The surface of the stoma is mucous membrane that is pink or red and moist-looking. The stoma tissue has many small blood vessels, and may bleed when cleaning and wiping it. The bleeding should not be of concern unless it fails to stop. The stoma may get smaller during the first weeks after surgery.
  • The part of the pouch that sticks to the abdomen is called a skin barrier wafer. The wafer opening for the stoma must fit snugly around it. Use the measuring guide that comes with ileostomy supplies to check the size of the stoma. As it gets smaller, the individual will need to reduce the size of the opening cut in the skin barrier wafer. If the skin wafer is too small, intestinal contents will leak and irritate the skin.
  • Irritated skin may also mean that the wafer has been left on too long. If the stoma becomes red or irritated, it is recommended to let a doctor know.
  • Cleaning and changing the pouch regularly will prevent unpleasant odors. The individual may also want to try different pouch deodorants. It may be best to change the pouch in the morning, before having anything to eat or drink, or at another time of day when the stoma is unlikely to be active. After time passes, the individual will probably get to know when to expect a bowel movement. If one is not on the way, the individual can take off the pouch and bathe or shower before putting on a clean replacement.
  • The length of time that the pouch stays tightly secured to the abdomen depends on many factors, such as the size and shape of the stoma and the shape of the belly. Large amounts of watery bowel movement will shorten the wearing time. If the pouch stays on for only one or two days, it is recommended to let an ETN, or doctor, know about the problem.
  • Changing disposable pouches: First, it is recommended by healthcare professionals to wash hands with soap and water. Use the measuring guide or pattern, trace the correct opening onto the skin barrier of the new pouch, then cut out the opening that was traced. Take off the paper backing that covers the adhesive on the skin barrier of the new pouch. Lay the pouch near with the adhesive side up.
  • Empty the old pouch into the toilet. Remove the pouch by pushing down on the abdomen with the fingers of one hand and peeling off the pouch with the other hand. Remove the clamp from the old pouch and save it for use with the new pouch. Put the used pouch into the plastic bag and throw away.
  • It is recommended to wash thoroughly around the stoma with mild soap and warm water. Do not use soaps that contain baby oil, cold cream, or perfumes. Rinse and dry the skin with a dry soft cloth. Do not leave any stool or wafer residue on the skin. The individual may want to shave or clip hairs around the stoma.
  • Next, center the pouch opening over the stoma. Press the skin barrier wafer onto the abdomen. Make sure there are no creases or wrinkles in the wafer. Squirt some pouch deodorant into the bottom pouch opening. Move the deodorant around the inside of the pouch with the fingertips. Use a piece of toilet paper to wipe deodorant off the opening. Put on the clamp that was removed from the old pouch. If the deodorant causes skin irritation, contact a healthcare provider.
  • Alerting medical care: A doctor should be called if the individual with an ostomy is vomiting or has diarrhea. Individuals who have an ileostomy can quickly get dehydrated. Signs of dehydration include dry mouth or tongue, a dry stoma, failure to urinate as much as normal, and dizziness on standing up. A doctor should also be called or the individual should be taken to a hospital if: they have severe abdominal pain; they vomit more than three times in one hour; they are too weak to stand up; they feel as though they are going to pass out; they cannot stop the stoma from bleeding; or they have an ileostomy and nothing has come out for several hours. This may mean that the intestines are blocked.

Selected references.
  • American Academy of Family Physicians. www.aafp.org.
  • American Gastroenterology Association. www.gastro.org.
  • American Society of Colon and Rectal Surgeons. www.fascrs.org.
  • Appleby SL, Eberhard MH, Spears MA. A home care wound care challenge: its rewards, inspiration, and positive outcomes. Home Healthc Nurse. 2007;25(6):362-8. View Abstract
  • Asfar SK, Al-Sayer HM, Juma TH. Exteriorized colon anastomosis for unprepared bowel: an alternative to routine colostomy. World J Gastroenterol. 2007;13(23):3215-20. View Abstract
  • Coons SJ, Chongpison Y, Wendel CS, et al. Overall quality of life and difficulty paying for ostomy supplies in the veterans affairs ostomy health-related quality of life study: an exploratory analysis. Med Care. 2007;45(9):891-5. View Abstract
  • National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). http://digestive.niddk.nih.gov.
  • Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com.
  • Richbourg L, Thorpe JM, Rapp CG. Difficulties experienced by the ostomate after hospital discharge. J Wound Ostomy Continence Nurs. 2007;34(1):70-9. View Abstract
  • Steele SE. When trauma means a stoma. J Wound Ostomy Continence Nurs. 2006;33(5):491-500; quiz 500-2. View Abstract
  • Voergaard LL, Vendelbo G, Carlsen B, et al. Ostomy bag management: comparative study of a new one-piece closed bag. Br J Nurs. 2007;16(2):95-6, 98-101. View Abstract

Copyright © 2011 Natural Standard (www.naturalstandard.com)


The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.

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