The Pharmaceutical Journal Vol 265 No 7125 p823-826
December 02, 2000 Special feature

Special feature

Stoma care — an update

By Julia Breeze, MSc-ANP, SNC

Aproximately 100,000 people in the United Kingdom are living with a stoma at any one time.¹ Stomas are categorised according to the classification outlined by Devlin² — input, diverting and output stomas (see Table 1). Stoma care nurses take care of the majority of patients with stomas and principally it is the last two categories that demand the largest proportion of their time.

Types of stoma

The word for stoma is derived from the Greek and means mouth or opening.⁴ This, to a person who is required to have the surgical procedure, means that an artificial opening is made from a hollow organ (eg, more commonly the colon or ileum, but also the stomach) and the opening is, usually, sutured or stitched on to the skin surface. This can be anywhere, but the abdomen, below the umbilicus and above the symphisis pubis, is the most usual area to find a stoma.
Colostomy A colostomy is formed from any part of the colon but is most commonly found on the left side of the abdomen from the descending or sigmoid colon.
Ileostomy An ileostomy is formed from the ileum, most commonly from the terminal ileum and is usually found on the right-hand side of the abdomen.
Urostomy A urostomy is also known as an ileal conduit because terminal ileum is used to make this type of formation. It is, however, made from a detached piece of ileum into which the ureters are fixed so that it is used purely for urine output. The ileum from which it is removed is re-anastamosed (joined) at the same time as the stoma is formed.
Accurate age distribution for those with these stomas is not known. Anybody of any age may have any of these stomas; however, it is the disease process that dictates the type of stoma.

Young people in their teens and twenties with inflammatory bowel disease are most likely to have an ileostomy. However, patients who have a mid to low rectal cancer (3-10cm from the anal verge) may also have a temporary ileostomy while the anastamosis heals. These patients are most commonly over the age of 55 years. Patients with bladder cancer tend to be over 60 and those requiring a cystectomy and ileal conduit (urostomy) are often much older than 60 at the time of surgery.

Appliances and accessories

Many of the types of stoma appliances used to manage faecal or urinary effluent are listed in the Drug Tariff. They vary depending upon the type of stoma the patient has, the patient's preference for management,⁵ and suggestions from stoma care nurses. Table 3 provides a summary of the range of appliances available. A one-piece appliance is an appliance with an adhesive attached and a two-piece appliance is one where the adhesive flange and pouch come separately. One-piece and two-piece appliances can be drainable, closed or can have a tap. Drainable appliances are for semi-liquid or liquid effluent and have a clip fastening. Closed appliances have a sealed pouch for solid or semi-solid effluent and usually have a flatus filter.
Taps on appliances are for urine output and have a "non-return valve "to prevent reflux. These may be used for excessively watery faecal effluent. Table 3 does not include the use of appliances with convexity, either integral or supplementary (these products, which can be found in addition to all the categories listed, will be dealt with below under "Problematic stomas”). A convex appliance is one that has a flange that is no longer flat. It curves outward in order to provide pressure on the surrounding peristomal skin when patients have been having problems in getting a leak-free seal from their appliance.
There is also a range of stoma care accessories that are in common use (Table 4). These include skin management products, which in themselves are a major topic of current research. This list should not be seen as definitive. A range of products should be offered to patients at the outset of stoma care.⁶

Dispensing of stoma products

Pharmacists in the community are currently able to earn up to 5 per cent of the total cost of each prescription for stoma care products. Dispensing appliance contractors (DACs) can earn up to 25 per cent of the cost of the same products. Stoma care nurses, particularly those in sponsored positions,⁷ are asked to encourage patients to use a DAC rather than a local pharmacy.⁸ The Department of Health is currently investigating this situation as it is estimated from NHS PACT (Prescribing Analysis and Cost) data that the NHS bill for stoma care is increased by many millions of pounds each year. Patients, however, anecdotally tell stoma care nurses that home delivery from a DAC is discreet, convenient and safer than having to depend on an order for bulky products that cannot be allowed to sit on a shelf until they are needed. There is obvious controversy over several issues here, including sponsorship, remuneration for provision of a service and the ethical dilemma of serving the best interests of the patient and the NHS.
A small group of nurses is currently working with the Royal College of Nursing to provide guidelines for nurses having to deal with the commercial sector, including pharmacists, of which many have little knowledge or experience. It is worth all professionals involved in the business of supplying stoma care products to be aware of the NHSE "Standards of business conduct for NHS staff”⁹ and the draft Health Service Circular 999 "Commercial sponsorship: ethical standards for the NHS”.¹⁰ These should be read and put into practice in order to provide a cohesive and ethically sound approach to both industry and patients.

Problematic stomas

Stomas inevitably cause problems that can lead to anxiety, distress and even depression for the patient.¹¹ While there are many references^12,13 relating to surgical problems and answers, there are few¹⁴that have measured the effect of problem stomas on the patient's quality of life. Stoma care problems are summarised in Table 5.
The incidence of problems ranges from 3-38 per cent of new stomas and these figures have been audited on an operating surgeon and trust basis. Stoma care nurses believe that 10 per cent would be an acceptable figure. Inevitably, established stomas sometimes cause problems¹⁵ but they become evident at a later stage, perhaps as a result of weight gain or loss and the effects of a particular life-style or occupation (eg, builders carrying heavy weights may be more prone to peristomal hernias and/or prolapse).
A problem stoma that is retracted or causes effluent leakage is commonly managed using a product that has a convex shaped flange. These convex appliances either have a convex shaped flange formation in-built during manufacture or, in the case of some two-piece appliances, may have a ring adaptation inserted into the flange before application to the body. They are more expensive than a conventional pouch but can save money that might otherwise be spent on accessory products in order to keep the appliance secure.¹⁶
Problems such as those outlined in Table 5 are expensive to manage, both in terms of time and products, but many could possibly be avoided if greater care was taken at the time of siting the stoma or during surgical formation. It is, however, accepted by stoma care nurses that there will always be some patients with problems relating to body contours, disease process and previous surgery etc. Patients need support, reassurance and considerable education if they are to be helped with problems and to avoid problems that do not require surgical intervention. Metcalf¹⁷ suggests that time spent on practical skills will also facilitate psychological adjustment to the stoma (ie, coping with an altered body image, grief and loss reactions to surgery and disease, having sexual malfunction as a result of surgery, having to adjust to diet and life style in order to live with a stoma). Stoma cares nurses spend a great deal of time on these activities.

Special dietary considerations

Stoma care nurses spend a considerable part of their time helping stoma patients with dietary problems. Some of these are perceived problems owing to the fact that bodily effluent is now visible. But the fact that problems are merly perceived does not invalidate the them.
Stoma care nurses need great diplomacy if they are to help the patient realise the importance of an adequate, nutritious diet. Inevitably, it is those patients with faecal effluent who require the most help but dietary requirements pertinent to each stoma type are dealt with briefly below. More detailed advice should be sought from a dietitian, if necessary.
Colostomists Colostomists worry most about odour and the amount of output. Offensive odour is directly related to food types such as eggs, onions and garlic. These things do not need to be avoided but patients may need to moderate their intake of these foods, as well as ensuring that their appliance fits properly and the flatus filter is not leaking.
An improperly fitting appliance will result in the escape of odour. If output is excessive (more than two closed pouches per day), the patient may be eating too much (particularly fibre) or may be anxious about having any effluent in the pouch, however minimal. All colostomists should eat a full range of foods that conform to recommended guidelines ie, high in fibre, low in sugar and salt.
Colostomists are at no less risk of constipation than the general population, so treating constipation should not be considered unusual. It is important to consider whether there may be any underlying disease process (eg, diverticulosis, recurrent carcinoma) or adverse effects of previous surgical intervention (abdominal adhesions or a narrowed anastamosis) that may be causing the constipation. These patients should be treated with caution.
Ileostomists Ileostomists require a diet entirely opposite from that of the general population (including colostomists), especially during the first few weeks after stoma formation. They should add salt to all meals (salt is lost from the terminal ileum into the appliance), reduce dietary fibre (taking all skin off tomatoes, all fruit, etc) and ensure that they have adequate fluid intake. Ileostomists may be advised that effluent output is reduced by wine and spirits but increased by beers.
If in any doubt about what to eat, ileostomists should note that an emergency ration of flat cola (with sugar) and crisps will suffice.
If the ileostomy is permanent, the patient should have their dietary intake supplemented by an intramuscular source of vitamin B₁₂ after two to three years, as this substance can no longer be absorbed. Patients should always be warned that eating beetroot is harmless but it will turn effluent red. Many a patient has spent an unnecessary night in an accident and emergency department having eaten beetroot and believing that they are passing copious amounts of blood. Urostomists Fluid intake is a urostomist's main concern. They should be advised to drink two to three litres of fluid per 24 hours. This is partly to prevent ascending urinary tract infections and also to flush out mucosal secretions, which are visible in the urinary output of any person with an ileal conduit. Most patients should be advised to drink cranberry juice,¹⁸ to prevent infection, unless they have previously had renal calculi.¹⁹
Initially, some urostomists complain of severe constipation in the recuperative period. This occurs as a result of bowel disturbance during the mobilisation of the ileum used to make this stoma. There may also be some sympathetic nerve disturbance²⁰ or damage from excision of the bladder (cystectomy). Constipation is best treated with a regular, gentle aperient such has co- danthramer, sometimes combined with a bulking agent (such as Fybogel) to assist returning regular peristalsis. A large intake of fluid should be part of their regular life style.

Problems with drug therapy

Stoma care nurses deal with patients with a myriad of diseases and conditions, as well as the many complications that result from surgery. All of these may require treatment with drugs. What is not always evident to a stoma care nurse is when the prescriber has taken into account the effects a particular substance may have on the stomal output. If the effluent alters because of new medication the patient will usually telephone the stoma care nurse first — the patient is unlikely to ask their pharmacist or return to the prescriber.²¹
There are several types of drug issues that should be considered in relation to the stoma patient:
Opioid analgesics Opioid analgesics inevitably cause severe constipation and colostomists are no exception. They should be treated like anyone else taking morphine or its derivatives. An ileostomist will notice reduced output but this does not usually cause problems. However, it is better for an ileostomist to be given a slow-release formulation of morphine rather than one that is rapidly absorbed. Cytotoxic agents Cytotoxics cause diarrhoea in many instances. For the colostomist this may mean the use of a drainable pouch temporarily, as well as the use of calming agents such as loperamide or codeine. For an ileostomist diarrhoea can be serious in that it may lead to severe dehydration. Loperamide in maximum quantities, together with codeine, may be required. Often salt has to be replaced in the form of a glucose and electrolyte mixture, such as Dioralyte, to avoid admission to hospital and intravenous therapy.
Contraceptive agents Contraceptive agents can be a problem for young females with an ileostomy. Absorption from the terminal eum is usually reduced in all ileostomists, so alternative forms of contraception should be considered. This is true for any agent that is usually absorbed in the final third of the small intestine.
Central nervous system agents The effects on the gut of some agents used to treat CNS conditions are often forgotten when they are prescribed. This is of particular relevance in ileostomists', whose output may increase when taking one of these substances. Dry mouth from tricyclic antidepressants may lead to an ileostomist drinking large quantities of fluid. This may cause the gut to be "flushed out "and the patient to have a large output. It is usually worth encouraging the patient to keep in contact with their stoma care nurse while adjusting to CNS agents.
Diuretics Diuretics should be prescribed with immense caution for an ileostomist as dehydration occurs easily. If these are required for an ileostomist, potassium sparing diuretics should be used and blood serum electrolyte levels regularly monitored.
Enteric-coated and slow-release preparations Enteric-coated tablets and slow-release medications should generally not be prescribed for patients with an ileostomy, as these preparations are not readily absorbed.
Enemas Enemas and washouts should never be prescribed or administered to those with an ileostomy unless permission has been obtained from the consultant. Perforation and damage to the small bowel mucosa is all too easy.

Conclusion

The implications of having a stoma are enormous for both the patient and for the many health care professionals involved in assisting with recuperation and maintenance of health. Stoma care nurses spend time dealing with new and established stoma patients with numerous medical conditions and needs.
Problem stomas are common and are demanding of time and attention. Psychosocial distress whether created, acquired or perceived as a result of stoma-forming surgery, requires support from a health care professional.
Stoma care nurses are usually more than willing to share their knowledge of appliances and the individual circumstances of patients with relevant healthcare professionals.
Helping these patients is rewarding, but it is only team effort, including the assistance of the self-help sector,²² and understanding that will enable all the issues raised in this article to be dealt with satisfactorily for a patient with a stoma.

Ms Breeze is a lead nurse for colorectal and stoma care services at the Royal Free Hampstead NHS trust. She was formally a clinical nurse specialist in a stoma care

References