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Indications and Care Essentials for Ostomies
Patricia Paxton‐Alan MSN ARNP‐BC CWOCN
OBJECTIVES
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OBJECTIVES
 State indications for two different types of ostomies  Identify types of stomas based upon: 
Anatomic Origin (type of ostomy)

Surgical Construction (type of stoma)
 Name two psychosocial issues that affect Health Related Quality of Life (HRQOL)  Discuss current trends in surgical ostomy management, ostomy care, and product advancements
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ANATOMY AND PHYSIOLOGY OF THE GASTROINTESTINAL SYSTEM
ANATOMY AND PHYSIOLOGY OF THE GASTROINTESTINAL SYSTEM
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ANATOMY AND PHYSIOLOGY OF THE GASTROINTESTINAL SYSTEM
SMALL INTESTINE
 Length: 20‐25 Feet  4 Layers:
Mucosa, submucosa, muscularis, and serosa
 Function:  Digestion and absorption of nutrients, vitamins, minerals, fluids, electrolytes, and miscellaneous items such as drugs  Neutralizes then converts acid chyme to alkaline for absorption  Processes 8 to 10 liters of fluid per day, approximately 1 to 2 liters pass into colon  Low pH:
pH 6‐7, due to low bacterial count  Transit time: 4 to 6 hours 7
INDICATIONS FOR SURGERY CROSSECTIONAL VIEW OF LAYERS OF THE GI TRACT
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ANATOMY AND PHYSIOLOGY OF THE GASTROINTESTINAL SYSTEM
SMALL INTESTINE (CONTINUED)
DUODENUM
 Length: 20 – 25 cm
 Location: Distal to Pyloris
 Function: Neutralize gastric contents, digestion, and absorption
JEJUNUM
 Length: 40 cm
 Location: After the Ligament of Treitz
 Function: Major organ of digestion and absorption of fats, proteins, and vitamins 9
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ANATOMY AND PHYSIOLOGY OF THE GASTROINTESTINAL SYSTEM
SMALL INTESTINE (CONTINUED)
ILEUM
Length: 60 cm Location: Distal to Jejunum Function: Absorption of any nutrients not absorbed by Duodenum and Jejunum Terminal Ileum contains the only receptor sites for absorption of Intrinsic Factor – Vitamin B12 Complex – , and for Bile Salts
ILEOCECAL VALVE
Size: 2‐3 cm ring of thick smooth muscle
 Location: Distal to Ileum, between Ileum and Large Intestine  Function: To regulate emptying into the Large Intestine, prevent reflux of contents back into Small Intestine  Transit Time: Average of 18 – 24 from Ileocecal Valve to Rectum
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ANATOMY AND PHYSIOLOGY OF THE GASTROINTESTINAL SYSTEM
LARGE INTESTINE
 Length: 5‐6 Feet  4 Layers: Mucosa, submucosa, muscularis, and serosa
 Function:  Collection, concentration, transport, and elimination of intestinal waste material  Absorption of water and electrolytes
 Motility organ for transporting feces  Produces mucous, lubrication of the fecal bolus  Common bacterial Flora:  Escherichia Coli  Aerobacter Aerogenes
 Clostridium Perfringens
 Lactobacillus Bifidus
Responsible for odor associated with feces 11
ANATOMY AND PHYSIOLOGY OF THE GASTROINTESTINAL SYSTEM
LARGE INTESTINE (CONTINUED)
CECUM
 Length: 6.0 ‐ 7.6 cm
 Location: Connects with Ileocecal Valve
 Function: Receives approximately 1.0 ‐ 1.5 liters of fluid from Small Intestine
Appendix arises from posteromedial aspect
ASCENDING COLON
 Length: 15 cm from Cecum to right Hepatic Flexure
 Function: Water, electrolytes (sodium, chloride), glucose, and urea are absorbed 12
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ANATOMY AND PHYSIOLOGY OF THE GASTROINTESTINAL SYSTEM
LARGE INTESTINE (CONTINUED)
TRANSVERSE COLON
 Length: 45 – 50 cm  Fixed:
At only 2 points: Hepatic Flexure & Splenic Flexure, highly mobile  Function: Consistency of colonic contents change from fluid to semi‐fluid DESCENDING COLON
 Length: 25 cm  Location: Extends from the Splenic Flexure to the brim of the True Pelvis
 Function: Water, electrolytes, and unabsorbed minerals are absorbed 13
ANATOMY AND PHYSIOLOGY OF THE GASTROINTESTINAL SYSTEM
LARGE INTESTINE (CONTINUED)
SIGMOID COLON
 Length: 40 cm
 Function: Water re‐absorption RECTUM
 Length: 12 ‐ 15 cm  Location:
Follows curve of Sacrum and Coccyx
 Function: Storage of feces ANAL CANAL
 Length: 3 ‐4 cm  Location:
Extends from Anal Rectal Junction to Anal Verge
 Function: Elimination of feces 14
ANATOMY AND PHYSIOLOGY OF THE GASTROINTESTINAL SYSTEM
LARGE INTESTINE (CONTINUED)
INTERNAL ANAL SPHINCTER  Involuntary  Relaxes while External Sphincter contracts allowing sensitive epithelium of the anal canal to “sample” contents to determine if liquid, gas, or solid EXTERNAL ANAL SPHINCTER  Voluntary
 Allows or prevents fecal elimination 15
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ANATOMY AND PHYSIOLOGY OF THE GENITOURINARY SYSTEM
ANATOMY AND PHYSIOLOGY OF THE GENITOURINARY SYSTEM
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ANATOMY AND PHYSIOLOGY OF THE GENITOURINARY SYSTEM
KIDNEY
 Length: 11 cm
 Width:
5 – 7 cm
Right kidney slightly inferior to left due to liver placement  Function:  Filtration of metabolic waste and toxins from the blood  Maintenance of internal homeostasis (maintains normal serum pH between 7.37 and 7.42)  Influences blood pressure, vascular volume, red blood cell production, apoptosis, and bone growth maintenance 18
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ANATOMY AND PHYSIOLOGY OF THE GENITOURINARY SYSTEM
URETERS
 Length: 24 – 30 cm
Left ureter typically longer than right because of the slightly inferior location of the right kidney
 Function:  Pushes a bolus of urine through the ureterovesical junction and into the bladder via peristalsis  Ureterovesical junction prevents reflux by sealing the ureter in response to contraction of the bladder 19
ANATOMY AND PHYSIOLOGY OF THE GENITOURINARY SYSTEM
BLADDER
Muscular, highly distensible organ  Length: 12.5 cm
 Width:
7.5cm
 Volume:  Ordinary amount: 470 cc  Ooooo (typical maximum): 600 – 800 cc  Function: Storage of urine 20
ANATOMY AND PHYSIOLOGY OF THE GENITOURINARY SYSTEM
URETHRA
 Length:  Female:
3.5 – 5.5 cm  Male : 23 cm
 Function:  Provides continence during bladder filling  Acts as a sphincter mechanism (entire length in females, proximal end in males)
Squeezes when cough or sneeze to help prevent urine leakage 21
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INDICATIONS FOR SURGERY INDICATIONS FOR SURGERY COLORECTAL CANCER INCIDENCE According to the CDC, in 2008 (the most recent year numbers are available)
 142,950 people in the United States were diagnosed with colorectal cancer,
including 73,183 men and 69,767 women
 52,857 people in the United States died from colorectal cancer, including 26,933 men and 25,924 women
 Colorectal cancer is one of the most common cancers in the United States  Relative survival rate at 5 years is currently 64.3% in the United States and increasing  Approximately 1 million people alive today have a history of colorectal cancer, making this cancer survivor population one of the largest in the United States
 Approximately 18% to 35% of colorectal survivors have received temporary or permanent intestinal ostomies as part of their treatment
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INDICATIONS FOR SURGERY FREQUENCY AND LOCATION OF COLON AND RECTAL CANCERS
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INDICATIONS FOR SURGERY COLORECTAL CANCER RISK FACTORS
 Diet  Low fiber
 High animal fat
 Alcohol
 Tobacco  Age
 Hereditary syndromes (Lynch Syndrome)
 Familial adenomatous polyposis (FAP)
 Hereditary nonpolyposis colorectal cancer (HNPCC)
 Inflammatory bowel disease (Crohn’s Disease, Ulcerative Colitis)  Personal and/or family history of colorectal cancer
 Polyps (adenoma)
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INDICATIONS FOR SURGERY COLORECTAL CANCER SYMPTOMS  Change in bowel habits  Diarrhea
 Constipation

Narrowing of stool  Incontinence
 Unexplained weight loss  Blood on or in stool
 Unexplained anemia  Abdominal pain or bloating 26
INDICATIONS FOR SURGERY CROHN’S DISEASE AND ULCERATIVE COLITIS  Cause unknown  Possibilities include immune system, virus or bacteria IBD
 Heredity, genetics may play a role
 Risk Factors
 Age, usually before age 30, secondary incidence 50’s to 60’s  Ethnicity, whites have the highest risk, may be seen in any ethnic group
highest risk in Ashkenazi Jewish descent
 Family history, higher risk if close relatives, parent siblings, of child
 History of Isotrentinoin use (previously known as Accutane)
 Cigarette smoking ‐ most important controllable risk factor for Crohn’s disease  Some pain relievers, Advil, Motrin, Aleve, and Aspirin  Geographic location, environmental factors, diet high in fat, refined foods people living in northern climates have a greater risk of disease  Incidence, highest
 North America:
CD: 20.2/100,00 UC: 19.2/100,000 27
 Europe: CD: 12.7/100,00 UC: 6.3/100,000 9
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INDICATIONS FOR SURGERY CROHN’S DISEASE AND ULCERATIVE COLITIS DIFFERENTIATION Crohn’s Disease Ulcerative Colitis Transmural
Superficial Focal, discontinuous involvement with aphthous ulcers, granulomas may be present
Continuous involvement with granularity,
friability, and pinpoint ulcerations May affect mouth to anus Limited to colon
Rectal involvement variable Rectum always involved Terminal ileum and cecum most commonly involved Small intestine not involved Peri‐rectal abscess/disease may be seen Peri‐anal area normal
Bleeding present with colonic disease Rectal bleeding common
Weight loss common due to small bowel involvement
Weight loss may occur Diarrhea depends on location of disease
Diarrhea common as weight loss presents
Percent of obstructive symptoms due to fibrosis and narrowing of lumen May have fever and/or night sweats Pain is likely due to transmural inflammation
Pain not typical 28
INDICATIONS FOR SURGERY CROHN’S DISEASE
Normal Colon Crohn’s Disease
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INDICATIONS FOR SURGERY CROHN’S DISEASE
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INDICATIONS FOR SURGERY ULCERATIVE COLITIS 31
INDICATIONS FOR SURGERY ULCERATIVE COLITIS 32
INDICATIONS FOR SURGERY DIVERTICULITIS  Cause
 Decrease in dietary fiber content  Constipation/straining  Diverticulosis
 Begins as diverticula
(pouches) form
 Diverticulitis occurs
 When diverticula become
inflamed and/or infected  Likely cause of infectious‐
inflammatory process is stool or food particles becoming
trapped in the pouches 33
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INDICATIONS FOR SURGERY DIVERTICULITIS CLINICAL PRESENTATION
 Left lower quadrant pain
 Nausea and vomiting  Fever  Change in bowel habits  Leukocytosis
 Rectal bleeding
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INDICATIONS FOR SURGERY DIVERTICULITIS  Increases in incidence with age, reaching a prevalence of greater than 65% in those older than 85 years. The mean age at presentation with diverticulitis appears to be about 60 years.  Significant association between obesity and the risk of developing diverticulitis.
 Genetics are believed to play a role, in addition to dietary factors. Left‐sided diverticula predominate in the United States. Asians, including Asian Americans, have a predominance of right‐sided diverticula.
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INDICATIONS FOR SURGERY FECAL INCONTINENCE  Accidental passing of solid or liquid stool or mucus from the rectum
 Approximately 18 million in US
 One in 12 people have fecal incontinence
 People of any age though more common in older adults and diabetics
 Slightly more common among women
RISK FACTORS
 Diarrhea, passing loose watery stools 3 or more times a day  Urgency, sensation of having little time to get to toilet for bowel movement
 After pelvic irradiation for malignancy  After surgical reconstruction of rectum for irritable bowel or cancer
 Trauma during childbirth with injuries to pelvic floor 36
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INDICATIONS FOR SURGERY FAMILIAL ADENOMATOUS POLYPOSIS (FAP)
 Most common adenomatous polyposis syndrome  Autosomal dominant inherited disorder  Characterized by the early onset of hundreds to thousands of adenomatous polyps throughout the colon
 If left untreated, all patients with this syndrome develop colon cancer by age 35‐40 years  Increased risk exists for the development of  Other malignancies
GARDNER’S SYNDROME
 Colonic polyposis typical of FAP
 Along with:  Osteomas commonly on the skull and the mandible  Dental abnormalities
 Soft tissue tumors
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INDICATIONS FOR SURGERY ISCHEMIC COLITIS  Acute, self‐limited compromise in intestinal blood flow which is inadequate for meeting the metabolic demands of a region of the colon
 90% of cases of colonic ischemia occur in patients over 60 years of age
 Younger patients may also be affected
RISK FACTORS
 Mesenteric artery emboli, thrombosis, or trauma
 Hypo‐perfusion states due to congestive heart failure, transient hypotension in the perioperative period or strenuous physical activities and shock due to a variety of causes such as hypovolemia or sepsis
 Mechanical colonic obstruction due to tumors, adhesions, volvuli, hernias, diverticulitis or prolapse
 There is a long list of medications that predispose to colon ischemia
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INDICATIONS FOR SURGERY VOLVULUS
 A twisting of any hollow viscus and can occur throughout the gastrointestinal tract  In the colon, volvulus can lead to obstruction and sometimes ischemia and perforation  Progressive proximal bowel distension occurs as a result of the obstruction, while gas distension of the closed loop increases intra‐luminal pressure over venous pressure leading to vascular congestion and eventual ischemia
 Twisting of the mesenteric vessels can also produce arterial insufficiency and venous thrombosis
 Most common anatomic locations for volvulus in the colon are the non‐
fixed regions, specifically the cecum, sigmoid and occasionally transverse portions
RISK FACTORS FOR SIGMOID VOLVULUS IN THE U.S.
 Male gender
 History of neuropsychiatric disease
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INDICATIONS FOR SURGERY VOLVULUS
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INDICATIONS FOR SURGERY INTUSSUSCEPTION
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INDICATIONS FOR SURGERY RADIATION ENTERITIS DAMAGE DURING OR FOLLOWING THERAPY
 The combination of acute and chronic radiation injury can result in varying degrees of inflammation, thickening, collagen deposition, and fibrosis of the bowel, as well as impairment of mucosal and motor functions
 Radiation enteritis is increasing and has been estimated to occur in 2‐5% of patients receiving abdominal or pelvic radiotherapy
 Reported higher numbers may be explained by the extent of radiation field, the technique, and the dosage of radiation used.  Cumulative 10‐year incidence of moderate injuries is estimated at 8%, and that of severe injuries is estimated at 3%
 Symptoms generally are insidious and develop months to years after therapy has ended
 Colicky abdominal pain, nausea and vomiting ‐ small bowel obstruction
 Chronic watery diarrhea  Possible development of fistulas 42
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INDICATIONS FOR SURGERY BLADDER CANCER INCIDENCE According to the American Cancer Society, in 2013  72,570 new cases of bladder cancer diagnosed, including 54,610 men and 17,960 women
 15,210 people in the United States died from bladder cancer, including 10,820 men and 4,390 women
 Bladder cancer is the fourth most common cancer in the United States  Relative survival rate at 5 years ranges from 15% to 98% in the United States depending upon stage. Early detection is important.  In 2010, there were an estimated 563,640 people living with bladder cancer in the United States 43
INDICATIONS FOR SURGERY BLADDER CANCER RISK FACTORS
 Cigarette smoking
 Chemical exposure, i.e., paints, dyes, rubber, leather, textiles
 Increasing Age
 Caucasian  Male
 Previous cancer treatment, i.e., radiation treatment  Personal and/or family history  Chronic long term bladder infections 44
INDICATIONS FOR SURGERY BLADDER CANCER SYMPTOMS  Painless hematuria (may be microscopic)  Frequency/urgency  Painful urination  Pelvic pain
 Back pain
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OSTOMIES BY THE NUMBERS
The number of patients living with stomas in the United States is unknown, but estimates range up to 450,000 people, with 120,000 new stomas created each year Other estimates predict the number of ostomates to increase by 3% per year Average age for all ostomates is 68.3 years The distribution of procedures is: 36.1% colostomy, 32.2% ileostomy, and 31.7% urostomy Approximately 30% to 40% of ostomies are estimated to be temporary 46
TYPES OF OSTOMIES AND STOMAS TYPES OF OSTOMIES AND STOMAS TYPES OF OSTOMIES
 Ileostomy ‐ Origin in Ileum
 Colostomy ‐ Origin in Colon
 Urostomy – Origin Ileum or Colon May be permanent or temporary 48
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FECAL OSTOMIES AND STOMAS FECAL OSTOMIES AND STOMAS TYPES BASED UPON:  Anatomic location (Ostomy)

Ileostomy

Colostomy
 Surgical Construction (Stoma)

End

Loop

Functional Stoma with Mucous Fistula ‐ Double Barrel 
Continent Stomas (with internal pouches) 50
FECAL OSTOMIES AND STOMAS OSTOMY BASED UPON ANATOMIC LOCATION ILEOSTOMY
Normal adult output:  Often liquid immediately after creation
 Amount varies between
800 and 1,700 mls/24 hrs
 Leveling off and gaining consistency in amounts between 500 and 1,800 ml/24 hrs
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FECAL OSTOMIES AND STOMAS INDICATIONS FOR SURGERY ILEOSTOMY
 Crohn’s Disease  Ulcerative Colitis  Colorectal Cancer
 Fecal Incontinence  Familial Adenomatous Polyposis  Gardener’s Syndrome  Congenital Anomalies  Trauma (gunshot wounds, etc.) 52
FECAL OSTOMIES AND STOMAS OSTOMY BASED UPON ANATOMIC LOCATION COLOSTOMY
Normal adult output:  Output depends on location
 The more distal to the Small Intestine the thicker and less frequent the output
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FECAL OSTOMIES AND STOMAS INDICATIONS FOR SURGERY COLOSTOMY  Colorectal Cancer
 Diverticulitis  Fecal Incontinence  Trauma, blunt or penetrating  Intestinal Obstruction, Volvulus, Intussusception  Radiation Enteritis, damage during or following therapy
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FECAL OSTOMIES AND STOMAS STOMA BASED UPON SURGICAL CONSTRUCTION
 End
 Loop
 Functional Stoma with Mucous Fistula ‐ Double Barrel  Continent Stomas (with internal pouches) 55
FECAL OSTOMIES AND STOMAS END STOMA Proximal end of intestine brought up to abdominal wall, everted, and attached to skin
Types of procedures for which End Stomas may be seen:  Adominoperineal Resection – Removal of rectum, anus, and sphincter mechanisms  Hartmann’s Procedure – Distal end of intestine closed, left in abdomen, may drain mucus/stool via rectum  Total Proctocolectomy with Ileostomy – Removal of entire colon and rectum  Abdominal (Subtotal) Colectomy – Portion of colon removed with rectal anastomosis, emergent procedure with toxic megacolon  Restorative Proctocolectomy – Total colectomy, rectal excision and construction of an ileal reservoir with an ileoanal anastomosis 56
FECAL OSTOMIES AND STOMAS STOMA BASED UPON SURGICAL CONSTRUCTION
END STOMA 57
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SURGICAL PROCEDURES ADOMINOPERINEAL RESECTION PROCEDURE
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SURGICAL PROCEDURES HARTMANN’S PROCEDURE
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SURGICAL PROCEDURES TOTAL PROCTOCOLECTOMY WITH ILEOSTOMY
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SURGICAL PROCEDURES ABDOMINAL (SUBTOTAL) COLECTOMY
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FECAL OSTOMIES AND STOMAS STOMA BASED UPON SURGICAL CONSTRUCTION
FUNCTIONAL STOMA WITH MUCOUS FISTULA
 Bowel severed, 2 ends brought through abdominal wall, 1 proximal and 1 distal
 Stapling devices have made these obsolete  Distal end will drain mucous 62
FECAL OSTOMIES AND STOMAS STOMA BASED UPON SURGICAL CONSTRUCTION
FUNCTIONAL STOMA WITH MUCOUS FISTULA
Indications:  If Hartmann’s closure not done  Distal un‐resectable
obstruction 63
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FECAL OSTOMIES AND STOMAS STOMA BASED UPON SURGICAL CONSTRUCTION
FUNCTIONAL STOMA WITH MUCOUS FISTULA
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FECAL OSTOMIES AND STOMAS STOMA BASED UPON SURGICAL CONSTRUCTION
DOUBLE‐BARREL
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SURGICAL PROCEDURES TYPES OF STOMAS BASED UPON SURGICAL CONSTRUCTION
KOCK POUCH – Continent Ileostomy
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FECAL OSTOMIES AND STOMAS STOMA BASED UPON SURGICAL CONSTRUCTION
LOOP STOMA Bowel brought through abdominal wall through transverse opening, everted, and matured. Rod placed under loop to prevent bowel from falling in to abdomen Created to protect a distal anastomosis or to manage a colonic obstruction Types of procedures for which Loop Stomas may be seen:  Low Anterior Resection – mobilize rectum with anastomosis below peritoneal reflection with temporary ostomy
 Abdominal (Subtotal) Colectomy – Portion of colon removed with rectal anastomosis
 Restorative Proctocolectomy – Second stage procedure for UC or Crohn’s
 Transverse Loop Colostomy – May be emergent divergent procedure, e.g., obstructive distal carcinoma 67
FECAL OSTOMIES AND STOMAS STOMA BASED UPON SURGICAL CONSTRUCTION
LOOP STOMA 68
FECAL OSTOMIES AND STOMAS STOMA BASED UPON SURGICAL CONSTRUCTION
LOOP STOMA 69
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FECAL OSTOMIES AND STOMAS STOMA BASED UPON SURGICAL CONSTRUCTION
LOOP STOMA Rod is typically removed by CWOCN on day 5 post‐op depending upon stoma evaluation/patient assessment 70
SURGICAL PROCEDURES RESTORATIVE PROCTOCOLECTOMY
ILEOANAL ANASTOMOSIS (J POUCH)
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SURGICAL PROCEDURES CONTRAINDICATIONS TO J POUCH
 Crohn’s  Severely malnourished, toxic  Cancer
 Obese
 Advanced age
 Incompetent anal sphincter 72
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URINARY OSTOMIES AND STOMAS URINARY OSTOMIES AND STOMAS NEPHROSTOMY
Urinary Diversion  Tube place in the kidney or bladder percutaneously
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URINARY OSTOMIES AND STOMAS INDICATIONS FOR SURGERY NEPHROSTOMY
 Urethral obstruction  Kidney stone(s)
 Stricture  Malignancy 75
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URINARY OSTOMIES AND STOMAS URETEROSTOMY
Urinary Diversion  Ureters mobilized and brought to skin surface  Poor candidate for intestinal diversions
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URINARY OSTOMIES AND STOMAS INDICATIONS FOR SURGERY URETEROSTOMY
 Poor candidates for intestinal diversions
 Not a procedure of choice  Lack of stoma creation
 Poor anatomic location
 High incidence of stenosis  Temporary measure for pediatric patients 77
URINARY OSTOMIES AND STOMAS ILEAL CONDUIT  Segment of small intestine utilized as conduit, proximal end closed, distal end brought out through opening in abdomen and used to create a stoma  Ureters implanted in small intestine segment 78
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URINARY OSTOMIES AND STOMAS INDICATIONS FOR SURGERY ILEAL CONDUIT
 Invasive bladder cancer
 Neurogenic bladder  Congenital anomalies  Refractory interstitial cystitis  Patient unable to manage a continent urostomy or neobladder 79
URINARY OSTOMIES AND STOMAS CONTINENT URINARY DIVERSIONS  Urinary reservoir created from isolated intestinal segments  Reservoir anastomosed to the ureters  Catheterizable stoma attached to the abdominal wall
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URINARY OSTOMIES AND STOMAS INDIANA AND MIAMI POUCHES
Continent Urostomy
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URINARY OSTOMIES AND STOMAS INDICATIONS FOR SURGERY CONTINENT URINARY DIVERSIONS
INDIANA POUCH AND MIAMI POUCH (gynecologic oncologic disease)  Bladder cancer  Neurogenic bladder  Congenital anomalies/Epispadias  Refractory interstitial cystitis  Patient physically able to undergo a lengthy surgical procedure
 Adequate renal function 82
URINARY OSTOMIES AND STOMAS NEOBLADDER
 Reservoir made from detubularized intestine attached to the ureters  Patient voids independently using native sphincter
 No stoma 83
URINARY OSTOMIES AND STOMAS INDICATIONS FOR SURGERY NEOBLADDER
 Cancer free trigone and urethra  Competent unobstructed urethral sphincter 84
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SURGICAL PROCEDURES TRENDS
 Enhanced Recovery After Surgery (ERAS) Programs
 Restorative Proctocolectomy – Total colectomy, rectal excision and construction of an ileal reservoir with an ileoanal anastomosis  Low Anterior Resection – mobilize rectum with anastomosis below peritoneal reflection with temporary ostomy  Restorative Proctocolectomy – Second stage procedure for UC or Crohn’s  Trends toward loop ileostomies for temporary diversion

Less odor, decreases prolapse and herniation, lower morbidity rates 
Flexible rods – comfort  Colorectal laparoscopic surgery common for stoma creation and expands surgical options
 Robotically-assisted surgery – Decreases OR time, blood loss, length of stay,
complications, conversion rates, post-op pain, and cost
85
PRINCIPLES OF STOMA MANAGEMENT
PRINCIPLES OF STOMA MANAGEMENT
3 PRIMARY PRINCIPLES:  Maintain pouch seal for predictable consistent wear time  Maintain peristomal skin integrity  Support person with stoma (psychologically and physically) 87
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PRINCIPLES OF STOMA MANAGEMENT
INDIVIDUALIZED PLAN TO EACH PATIENT
BASED UPON THE FOLLOWING:
 Stoma characteristics





Mucosa
Protrusion Anatomic location
Size and shape
Lumen  Stoma construction
 Stoma function/volume and consistency of effluent  Peristomal skin integrity  Peristomal plane characteristics  Patient’s preferences and requirements 88
PRINCIPLES OF STOMA MANAGEMENT
INDIVIDUALIZED PLAN BASED UPON THE FOLLOWING:
STOMA CHARACTERISTICS
MUCOSA Normal:  Red, moist, shiny, taut  Edematous
 Shrinks in size up to 8 weeks after surgery  No nerve endings
 Intact mucocutaneous junction  Analogous to inside of cheek Abnormal:  Grey, brown, black, flaccid  Indicates impaired blood flow 89
PRINCIPLES OF STOMA MANAGEMENT
INDIVIDUALIZED PLAN BASED UPON THE FOLLOWING:
STOMA CHARACTERISTICS
PROTRUSION  Ideally 1.0 to 1.5 cm above skin  Flush stoma may require convexity  Excessively long stoma may be injured ANATOMIC LOCATION  Dictates selection of appliances  Physical location on abdomen does not necessarily indicate anatomic origin, i.e., RLQ is always a ileostomy is not necessarily true 90
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PRINCIPLES OF STOMA MANAGEMENT
INDIVIDUALIZED PLAN BASED UPON THE FOLLOWING:
STOMA CHARACTERISTICS
SIZE AND SHAPE  Depends upon reason for creation
 Type of stoma
 Surgical creation  Round, oval, mushroom Measure stoma at longest and widest diameter STOMA LUMEN (OPENING)  Dictates direction of flow of effluent  Ideal lumen is straight up  Lumen at skin level may require convexity, seal 91
PRINCIPLES OF STOMA MANAGEMENT
INDIVIDUALIZED PLAN BASED UPON THE FOLLOWING:
STOMA FUNCTION/VOLUME AND CONSISTENCY OF EFFLUENT  Depends on type and anatomic location
 Oral intake (solids and liquids)
 Medications  Degree of ambulation  Flatus expelled related to swallowed air and/or bacteria 92
PRINCIPLES OF STOMA MANAGEMENT
INDIVIDUALIZED PLAN BASED UPON THE FOLLOWING:
PERISTOMAL SKIN INTEGRITY
 Normal: healthy and intact PERISTOMAL PLANE CHARACTERISTICS  Refers to surface area located under skin barrier and adhesive of pouch system including area surrounding stoma  Helps to determine shape, size, and construction of barrier required  If possible, examine patient in supine, sitting, bending, and standing
positions
 Examine skin firmness/softness around stoma 93
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PRINCIPLES OF STOMA MANAGEMENT
INDIVIDUALIZED PLAN BASED UPON THE FOLLOWING:
PERISTOMAL PLANE CHARACTERISTICS 94
PRINCIPLES OF STOMA MANAGEMENT
INDIVIDUALIZED PLAN BASED UPON THE FOLLOWING:
PERISTOMAL PLANE CHARACTERISTICS 95
PRINCIPLES OF STOMA MANAGEMENT
INDIVIDUALIZED PLAN BASED UPON THE FOLLOWING:
PERISTOMAL PLANE CHARACTERISTICS 96
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PRINCIPLES OF STOMA MANAGEMENT
INDIVIDUALIZED PLAN BASED UPON THE FOLLOWING:
PATIENT’S PREFERENCES AND REQUIREMENTS  Depends upon patient’s level of knowledge concerning procedure  Patient’s ability and competence, e.g., visually impaired, mentally impaired, compromised dexterity  Need for open‐end transparent pouch while in hospital  Activities of daily living requirements 97
PRODUCT SELECTION AND POUCHING PRINCIPLES PRODUCT SELECTION AND POUCHING PRINCIPLES Type of Stoma: Primary Impact on Choice of Management System 99
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PRODUCT SELECTION AND POUCHING PRINCIPLES STANDARD OR EXTENDED WEAR BARRIERS
The difference is how they interact with moisture and adhere to the skin  Standard – Colostomy
 Extended Wear – Ileostomy and Urostomy
SHAPE OF BARRIER  Flat – Level skin contact area
 Convex – Outward curve that begins at aperture of skin barrier and extend outward  KEY: Shape of skin barrier should be a mirror image of the topography of the peristomal plane 100
PRODUCT SELECTION AND POUCHING PRINCIPLES SKIN BARRIER SELECTION
SKIN BARRIER MUST  Provide predictable wear time (typically 4 days)
 Protect the peristomal skin SKIN BARRIER FUNCTION
 Protect peristomal skin from effluent
 Create a level pouch surface  Solid and Paste skin barriers provide an adhesive seal Solid skin barriers may contain polymers, tackifiers, softeners, plasticizers, hydrocolloids, fillers, and pigment 101
PRODUCT SELECTION AND POUCHING PRINCIPLES SKIN BARRIER SELECTION
102
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PRODUCT SELECTION AND POUCHING PRINCIPLES POUCH SELECTION
POUCH MUST  Be emptied when 1/3 to 1/2 full
 Should be replaced after 2 days of wear if possible POUCH FUNCTION
 Contains stool/effluent/urine
 Odor control (filters available) 103
PRODUCT SELECTION AND POUCHING PRINCIPLES POUCH SELECTION
TWO PIECE POUCH Available in many shapes, sizes, and configurations, open and closed end  First considerations in choosing are length and film
 Choice of length depends on volume of stoma output and personal preference  Film (transparent or opaque)  Fabric or plastic backing – quiet (less crinkling)  Skin barrier with flange, detachable pouch with access to stoma
 Low profile desired – minimal detection under clothes  Pouch positioning on abdomen (oblique during hospital stay for emptying)
 Pouch Closure – Velcro like or tail closure
 Lifestyle friendly (versatile)
 Urostomy pouches have a tap (may be used for high output ileostomy patient)
104
PRODUCT SELECTION AND POUCHING PRINCIPLES POUCH SELECTION
ONE PIECE POUCH Pouch with Barrier attached  Very conformable  Excellent option for the obese  One‐step application
 Flexible
 Lightweight
 Flat or convex (integral)
 Used for situation where even the use of convexity may be difficult
105
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PRODUCT SELECTION AND POUCHING PRINCIPLES POUCH SELECTION
TWO PIECE 106
PRODUCT SELECTION AND POUCHING PRINCIPLES POUCH SELECTION
TWO PIECE OPTIONS SUR‐FIT Natura® Closed‐End Pouch with Filter
SUR‐FIT Natura® Drainable Pouch with InvisiClose™ tail closure
107
PRODUCT SELECTION AND POUCHING PRINCIPLES POUCH SELECTION
ONE PIECE 108
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PRODUCT SELECTION AND POUCHING PRINCIPLES ACCESSORIES
EAKIN COHESIVE® SEALS
109
Eakin Cohesive is a registered trademark of T.G. Eakin Limited
PRODUCT SELECTION AND POUCHING PRINCIPLES ACCESSORIES
NIGHT DRAINAGE SYSTEM 110
PRODUCT SELECTION AND POUCHING PRINCIPLES ACCESSORIES
3M™ Cavilon™ No Sting Barrier Film
 Pouch covers available 111
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PRODUCT SELECTION AND POUCHING PRINCIPLES USES OF CONVEXITY  Flush stoma with effluent undermining barrier  Location of stoma lumen at skin level  Peristomal fistula  Stoma retraction  Abdominal creases, folds, and crevices, etc. 112
PRODUCT SELECTION AND POUCHING PRINCIPLES Flush, Retracted Stoma 113
PRODUCT SELECTION AND POUCHING PRINCIPLES GOALS FOR CONVEXITY
 To provide a mirror image of the skin around the stoma
 To maintain a secure seal between the pouch and the skin
 To obtain a predictable and sustained wear time
 To provide cost‐effective ostomy care
 To reduce the potential for complications
 To increase patient satisfaction
114
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STOMA/PERI‐STOMAL COMPLICATIONS
STOMA/PERI‐STOMAL COMPLICATIONS
GENERAL POINTS
 Occurs with almost every ostomate at some point  Risk Factors  Obesity  Inflammatory Bowel Disease  Stomas created in emergent situations 116
STOMA/PERI‐STOMAL COMPLICATIONS
CANDIDIASIS
Overgrowth of Candida organism causing inflammation, infection, or disease on peristomal skin  May present as pustule which abrades upon removal of barrier adhesive, may see papules, erythema, maceration  Patient complains of itching/burning
 Satellite lesions may be seen at edge of rash  Generally limited to under adhesive seal (warm, dark environment)  Risk Factors  Antibiotics
 Surgery  Moist environment (leakage)  Diabetes  Immunosuppressant drugs MANAGEMENT  Identify and correct cause of moist environment, if cause
 Topical antifungal powder (Microguard Powder with 3M No‐Sting barrier film 117
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STOMA/PERI‐STOMAL COMPLICATIONS
Candidiasis
118
STOMA/PERI‐STOMAL COMPLICATIONS
MUCOCUTANEOUS SEPARATION Detachment of stoma from skin at Mucocutaneous junction  May result from poor healing, tension or superficial infection  Risk Factors  Diabetes  Malnutrition  Immunocompromised status  Corticosteroids  Infection  Stoma necrosis  Disease recurrence MANAGEMENT  Assess peristomal junction by gently probing with Q‐Tip, determine depth and amount of circumference involved
 Determine tissue status (red – granular, yellow – fibrinous, black – necrotic)  Separation filled with absorbent materials, i.e., hydrofibers
 Assess stoma frequently for changes, retraction/stenosis
119
STOMA/PERI‐STOMAL COMPLICATIONS
Mucocutaneous Separation
120
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STOMA/PERI‐STOMAL COMPLICATIONS
IRRITANT DERMATITIS Skin damage resulting from contact with fecal or urinary drainage or chemical preparations  Skin damage located in sites exposed to stool, urine, or solvents  Possibly from inadequate pouch seal, incorrect sizing, poor pouch technique, poor stoma location, prior peri‐stomal skin status  Effluent destroys and erodes the epidermis  Initially skin is red or with macular rash, may rapidly progress towards denudement
 Incidence varies 2.5% to 55% of ostomates
MANAGEMENT  Correct etiology  Treat denuded skin – Stomahesive powder and 3M No‐Sting Barrier Film (Use crusting technique)  Apply Triamcinolone Acetonide spray (Kenalog 60g), allow to dry, place Duoderm X‐tra Thin barrier around stoma prior to barrier and pouch application  Prevention of reoccurrence through education 121
STOMA/PERI‐STOMAL COMPLICATIONS
Irritant Dermatitis
122
STOMA/PERI‐STOMAL COMPLICATIONS
RETRACTION
Stoma protrusion disappearing to or below skin level




Difficult to maintain seal Effluent may undermine Stoma may totally disappear from view when patient sits
Risk Factors  Obesity, short mesentery  Excessive adhesions/scar  Stoma length inadequacy, initially  Improper skin excision  Necrotic stoma  Mucocutaneous Separation MANAGEMENT  Convex pouching system with belt
 Referral to colorectal surgeon 123
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STOMA/PERI‐STOMAL COMPLICATIONS
Retraction
124
STOMA/PERI‐STOMAL COMPLICATIONS
UNDERMINING/LEAKAGE
Effluent under barrier on peri‐stomal skin
 Use correct size ostomy barrier
 Always change barrier at the first sign of leakage
 Never patch barrier with tape or paste – Leaks need to be fixed!
 Empty pouch contents when 1/3 to no more than 1/2 full  Use gas filter to release pressure  Consult with CWOCN, pharmacist to learn about medications to reduce gas 125
STOMA/PERI‐STOMAL COMPLICATIONS
Undermining
126
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STOMA/PERI‐STOMAL COMPLICATIONS
PROLAPSE – LATE PRESENTATION Telescoping of bowel though the stoma, varies in length up to greater that 1 foot
 Incidence varies from 1 to 16%, usually occurs in loop stomas
 Risk Factors  Obesity
 Increased intra‐abdominal pressure
 Chronic obstructive pulmonary disease (COPD)  Bowel redundancy
 Weak fascia  Technical factors that can lead to prolapsed stoma  Improper stoma site outside the rectus muscle
 Oversized aperture
 Redundancy of the distal bowel at the stoma site MANAGEMENT  Medical emergency requiring ED visit if stoma becomes in color and painful  One piece flexible appliance 127
STOMA/PERI‐STOMAL COMPLICATIONS
Prolapse
128
STOMA/PERI‐STOMAL COMPLICATIONS
PARASTOMAL HERNIA
Defect in fascia allowing loops of intestine to protrude into areas of weakness
 Appropriate stoma siting may minimize occurrence  Presents as unsightly bulge either in one area or total area surrounding stoma
with patient in sitting and/or standing position  Patient may be insecure regarding pouch leaking  Psychologically distressed regarding unsightly bulge  Patient may complain of pain in the area of hernia MANAGEMENT  Must wear one piece pouch system  Hernia support belt/binder (Celebration, Nu‐Hope) must be measured  Stool should be kept soft and pasty – prevent constipation  Monitor color of stoma, if dark/dusky seek medical attention  Schedule regular medical appointments, monitor hernia status 129
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STOMA/PERI‐STOMAL COMPLICATIONS
Parastomal Hernia 130
STOMA/PERI‐STOMAL COMPLICATIONS
NECROSIS From impairment of blood flow through the stoma tissue resulting in stoma death
 Presents dark in color varying from maroon to black , flaccid to the touch
 Generally occurs within 24 hours after surgery
 May involve a portion, half, or all of the stoma above and below the fascia
 Reported incidence of early stoma necrosis ranges from 4.3% ‐ 17%  Risk Factors  High BMI (Body Mass Index)  Short bowel
 Bowel edema These can increase mesenteric tension and consequently lack of blood flow
MANAGEMENT  Monitored with flashlight and lubricated pediatric test tube for viability  One piece cut to fit transparent ostomy pouch only  Can be a surgical emergency
 If blood flow is compromised at fascia level, patient must return to surgery for a 131
revision STOMA/PERI‐STOMAL COMPLICATIONS
NECROSIS Necrotic Stoma
132
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PRE‐OPERATIVE CONSIDERATIONS
PRE‐OPERATIVE CONSIDERATIONS
PATIENT ASSESSMENT  Medical and Surgical History
 Type of Surgical Procedure Scheduled  Educational Level, Mental and Emotional Acuity  Support System – Psychological and Social Support, Financial Issues  Coping Styles  Cultural and Spiritual Issues  Sexuality  Language Barriers  Vision  Hearing
 Hand Dexterity and Motor Skills  Skin Sensitivity/Allergy  Other Physical Challenges 134
STOMA SITE MARKING
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PRE‐OPERATIVE CONSIDERATIONS
STOMA SITE MARKING
 Is a pre‐op activity performed by:  Certified Wound Ostomy Continence Nurse (CWOCN)
or
 Colorectal Surgeon  Pre‐op teaching occurs during stoma‐siting
136
PRE‐OPERATIVE CONSIDERATIONS
STOMA SITE MARKING
WHY STOMA SITE?
 Patient needs to visualize stoma  Assists surgeon with stoma placement
 Promote adequate appliance adhesion
 Prevent future stoma complications
 Opportunity for pre‐operative education
137
STOMA SITE MARKING
 One of the most important aspects of care provided by a WOC nurse  Recommended by the American Society of Colorectal Surgeons (ASCS)  A retrospective study of 1,616 medical records of persons who underwent ostomy surgery found that stoma site marking by a CWOCN decreased the incidence of stoma complications by half, suggesting that pre‐operative stoma site marking reduces the risk for developing ostomy complications  A trained clinician can perform stoma site marking in the absence of a CWOCN or Colorectal Surgeon  Should be provided for temporary or permanent stomas 138
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STOMA SITE MARKING
PATIENT EXAMINED:  Supine
 Sitting  Bending /Standing
LANDMARKS:  Beltline  Umbilicus
 Iliac crest
 Rectus muscle
 Infra‐umbilical bulge
139
STOMA SITE MARKING
140
STOMA SITE MARKING
PLACEMENT:  Within borders of rectus muscle on apex of infra‐umbilical bulge  Avoid skin folds, deep creases, bony prominences, and beltline, if possible
 Location visible to patient
 Provision of 2.5 inches of adhesive surface for pouching system
DOCUMENTATION:
 Patient in agreement with stoma site 141
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POST‐OPERATIVE ACTIVITIES
POST‐OPERATIVE ACTIVITIES
WHAT’S THIS?
143
POST‐OPERATIVE ACTIVITIES
POST‐OPERATIVE COMMUNICATION
 When communicating with stoma patients, you need to take account of both their practical and emotional needs
 Physical needs – how the stoma is managed
 Emotional needs – how the patient feels about their condition  Consider how you would feel if you were told you had to wear a pouch on your abdomen to collect feces and how this would affect the way you thought about your body
 Sensitive communication includes:  Using the right kind of language  Being aware of your facial expressions/body language  Dealing with a stoma is a very intimate and personal subject  Listen to the patient and let them talk about their concerns and worries
144
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POST‐OPERATIVE ACTIVITIES
KEY POST‐OPERATIVE EDUCATION COMPONENTS
 In‐depth discussion of anatomy and physiology of the GI tract  Technical aspects of ostomy management (demonstration and return demonstration recommended)  Pouching system removal and application  Pouch emptying and closure (demonstration and return demonstration recommended)  Skin care  Ostomy accessories  Nutrition/medications  Clothing  Body image perception  Psychological aspects  Social/recreation  Interpersonal relationships  Sexual issues  Intimacy issues  Common complications/troubleshooting 145
POST‐OPERATIVE ACTIVITIES
CULTURAL AND RELIGIOUS CONSIDERATIONS
 Be sensitive to the religious and cultural issues which may affect the patient
 Ask for further information when you are unfamiliar with particular requirements  There can be wide variety of different beliefs and practices
 How strictly practices are observed vary greatly, so it is important not to make assumptions
 Make sure you understand the needs of each patient as a unique individual
 In certain cultures, having a stoma may be regarded as “unclean”, adding to the difficulties for the patient in adjusting  Ritual washing before prayer is required within some faiths, such as Islam or Hinduism
 Devout Muslims may be reluctant to use their right hand when cleaning their stoma (the right hand being used for eating, the left hand for cleaning and hygiene)
 Dietary requirements or the need for fasting can affect the frequency and consistency of the stoma output
146
POST‐OPERATIVE ACTIVITIES
TEACHING
 Assess learner readiness (teach in small steps)  Use of pouch clamp  Looking at and measuring stoma  Transferring measurement to the barrier (appropriate size selection or cut)  Application of Eakin Seal around base of stoma, if indicated  Placing barrier around base of stoma  If two piece system, snapping pouch onto barrier  Placing clamp on tail closure of pouch  Emptying and rinsing pouches  Peri‐stomal skin inspection 147
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POST‐OPERATIVE ACTIVITIES
TEACHING
KEY ISSUES
 Edema lasts up to 8 weeks  Gas and odor  Bathing and showering – with or without pouch (picture frame of tape)
 Clothing styles – no need to change unless stoma on higher plane  Sexual function – pouch should be empty before activity, covers available  Activities of daily living  All activities acceptable, poly‐material caps available for boxing, etc  Wear time:  Average barrier wear time in US is 4.8 days  Type of stoma and length of time since creation significantly affect wear time
 No significant relationship between geographic location, age, gender, or 148
BMI and wear time (skin condition – age) POST‐OPERATIVE ACTIVITIES
TEACHING
DIET  Use of gas filters, prevention of swallowing air, limit use of straws, refrain from smoking
 Frequent small meals  Fecal Ostomy – Same foods caused gas pre‐op will cause gas post‐op: beans, onions, broccoli, cabbage, cauliflower, beer, eggs  Ileostomy –
 Adequate fluid intake, must drink 8‐10 eight oz glasses of fluid per 24 hrs
Must include fluids containing K+ and Na+ to prevent dehydration (Powerade, Gatorade, etc.; sugar‐free for diabetic patients )
 Educate patient regarding foods that can increase consistency of fecal output, i.e., bananas, rice, pasta, cheese, applesauce, pretzels, white bread or toast, Rice Krispies
 Avoid high fiber foods, i.e., coconut, nuts, dried fruit, potato skins, Chinese food, stringy foods, celery 149
POST‐OPERATIVE ACTIVITIES
TEACHING
DIET (continued)  Urostomates need to drink 2,000 – 2,500 ml of liquids a day to help prevent bacterial overgrowth and maintain urine pH in acidic range MEDICATIONS Most important consideration is length of small bowel for drug absorption  Ileostomy patients  May require antidiarrheals
Loperamide (Imodium) dose for high output ileostomy: 4 mg twice a day for 4 days, then may increase to 12mg daily for 3 days
Diphenoxylate (Lomotil) dose: 2 tables po 4x daily or 10ml solution po 4x daily, then decrease to amount necessary to maintain bowel movement
 Should never use laxatives  Enteric coated medications not absorbed
 Colostomy patients develop constipation with calcium carbonate antacids/Ca+ 150
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POST‐OPERATIVE ACTIVITIES
IMPORTANT J POUCH POST‐OP CONSIDERATIONS
 High ileostomy output: 1,000 – 2,000+ ml/24 hours, illeostomy bypasses 20% or more of distal bowel leading to dehydration  Inform Patient:  Of signs and symptoms of dehydration  To modify diet to include foods/liquids that will thicken stoma output  To take anti‐diarrheal medications to slow output and encourage absorption  Loop ileostomy (almost flush to skin) requires extended‐wear skin barrier and convex barriers are frequently necessary  Educate patient regarding foods that can increase consistency of fecal output
 Bananas, rice, pasta, potato, noodles, cheese, applesauce, pretzels, white bread, Rice Krispies
 Inform patient that rectal pressure/fullness may be present, sitting on toilet expelling rectal contents is expected, mucous may be expelled
151
POST‐OPERATIVE ACTIVITIES
TEACHING
HEALTH RELATED QUALITY OF LIFE (HRQOL) – PATIENTS’ CONCERNS  Impaired body image
 Fear of incontinence  Fear of odor
 Limitations affecting:  Social activities
 Travel‐related activities
 Leisure activities
 Impaired sexual function HRQOL significantly highest among patients satisfied with their care and when they ranked the ostomy nurse as having a genuine interest in them as individuals 3 longitudinal studies demonstrate HRQOL rises steadily during first post‐op year, especially among young adults Greatest rise in HRQOL occurs between the immediate post‐op period and the 3rd post‐op month and gradually improves over the 1st post‐op year 152
POST‐OPERATIVE ACTIVITIES
TEACHING
OTHER FACTORS THAT INFLUENCE HRQOL
 Underlying reason for the ostomy





Presence and severity of ostomy complications Presence and severity of comorbid conditions Sexual function Age Ability to pay for ostomy supplies SUPPORT GROUPS  National: United Ostomy Association of America (UOAA)
 Local:  Broward Health Coral Springs “Caring and Sharing”  Broward Ostomy Association (BOA) OUTPATIENT CENTER  Broward Health Coral Springs
153
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POST‐OPERATIVE ACTIVITIES
TEACHING
OTHER RESOURCES  American Cancer Society at www.cancer.org
 Broward Ostomy Association at www.browardostomy.org
 C3Life Community Connection Center at www.c3life.com
 Crohn's Colitis Foundation of America CCFA at www.ccfa.org
 Friends of Ostomates Worldwide at www.fowusa.org
 Gay & Lesbian Ostomates at www.glo‐uoaa.org
 Great Comebacks at www.greatcomebacks.com
 International Ostomy Association at www.ostomyinternational.org
 United Ostomy Associations of America at www.uoaa.org
 Wound Ostomy Continence Nurses Society at www.wocn.org
154
POST‐OPERATIVE ACTIVITIES
TEACHING
MANUFACTURER LINKS
 Bag It Away Ostomy Disposal Bags at http://bagitaway.com
 Celebration Ostomy Support Belt at www.celebrationostomysupportbelt.com
 Coloplast at www.coloplast.com
 ConvaTec at www.convatec.com
 Cymed Incorporated at www.cymed‐ostomy.com
 Hollister Incorporated at http://hollister.com
 Marlen Manufacturing & Development Company at www.marlenmfg.com
 Nu‐Hope Laboratories at www.nu‐hope.com
 Osto‐EZ‐Vent at www.kemonline.com
 Parthenon at www.parthenoninc.com
 Smith & Nephew Inc. at www.smith‐nephew.com
 Sto Med Inc. at www.sto‐med.com
155
POST‐OPERATIVE ACTIVITIES
TEACHING
TROUBLESHOOTING ASSISTANCE  Refer to written and pictorial educational material  Utilize provided home healthcare nurse
 Contact CWOCN  Contact Colorectal Surgeon  Refer to provided lists of resources  Support Groups
 Websites  Organizations  Contact manufacturers  Refer to mental health provider if indicated
156
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uide
Colwell JC, Goldberg MT, Carmel JE. In Fecal and Urinary Diversions, Management Principles. St. Louis: Mosby; 2004 104‐
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consensus‐review‐of‐optimal‐perioperative‐care.pdf. (n.d.). Retrieved from https://scoap.files.wordpress.com/2010/07/consensus‐review‐of‐optimal‐perioperative‐care.pdf
DescriptionofOstomySurgeries.pdf. (n.d.). Retrieved from http://my.clevelandclinic.org/Documents/Digestive_Disease/DescriptionofOstomySurgeries.pdf
dietary‐strategies‐for‐fecal‐incontinence.pdf. (n.d.). Retrieved from http://my.clevelandclinic.org/Documents/Digestive_Disease/woc‐spring‐symposium‐2013/dietary‐strategies‐for‐fecal‐
incontinence.pdf
Diverticulitis. (2013). Retrieved from http://emedicine.medscape.com/article/173388‐overview#aw2aab6b2b4aa
Doughty, D. B. (2008). History of ostomy surgery. Journal of Wound Ostomy & Continence Nursing, 35(1), 34–38.
Edwards BK, Ward E, Kohler BA, et al. Annual report to the nation on the status of cancer, 1975–2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer. 2010;116:544–573. 158
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