Definitions for the levels of evidence (LE) (1a-4) and grades of recommendation (GR) (A-C) are provided at the end of the "Major Recommendations" field.
Principles of Management: Nursing Interventions
Activities of Daily Living (ADL)
Pre-operative assessment of the functional status of the patient, including data about work, sport activities and home-making. (LE=4, GR=C)
Social Context and Support
- Pre-operative assessment of social circumstances to identify any requirement for physical alterations to home. (LE=3, GR=C)
- Pre-operative assessment of eligibility for financial support. (LE=3, GR=C)
- Inclusion of family member at pre-operative assessment to establish support mechanism. (LE=3, GR=C)
- Provision of written information at pre-operative stage to clarify and support discussions. (LE=3, GR=C)
Psychological Aspects, Compliance and Cognition
- Pay special attention to patients with a history of mental illness. (LE=4, GR=C)
- Pre-operative assessment of psychological capability essential. (LE=4, GR=C)
- Audio or visual information should be provided. (LE=4, GR=C)
Cultural and Religious Issues1
- Be aware of the patient's country of origin and religion. (LE=4, GR=C)
- Note their individual 'feast, festival and fasting calendar'. (LE=4, GR=C)
- Maintain the patient's dignity at all times. (LE=4, GR=C)
- Understand cultural dietary/product usage considerations, e.g., gelatine (animal product). (LE=4, GR=C)
- Provide translators when necessary. (LE-4, GR=C)
- Promote cultural awareness among team members. (LE=4, GR=C)
1Recommendations from Black P. Practical stoma care. Nurs Stand 2000;14(4):47-53.
Siting (Site Marking)
|Table: Siting (Site Marking) Procedure2
- Inform the patient about the aim and procedure and be aware that site marking should be a joint decision of the patient and (stoma care) nurse. This is because consent promotes acceptance.
- Collect all relevant information about the disorder and the planned surgery. This is because different stomas have different preferences for site marking.
- Collect patient-specific information about lifestyle, profession, body, skin, religion, orthopaedic aids, hobbies and sports. This is because wheelchair-bound patients, or patients who wear orthopaedic aids, should not be hindered by the stoma. Always carry out the site marking with patients in their wheelchair or using their aid.
- Let the patient lie down on the bed and let him/her hitch up the abdomen. This is because stomas will be placed within the rectus abdominus.
- Make an imaginary line between the umbilicus, the pelvic crest and the os pubis. Mark the place as an orientation point marking where the stoma can possibly come out. Within this triangle, the stoma will preferably be placed, leaving enough room for the flange.
- Let the patient bend and sit so that possible folds and dips can be registered. This will help to prevent leakage by folds and pits and enable the device to be adequately fitted.
- Discuss clothing in relation to the site marking. This can prevent patient disappointment and limitation of ADLs and daily habits and prevent complications.
- Check that the site is visible in different positions and is accessible for the patient, so that the patient can take care of his/her stoma.
- Eventually, place a test pouch over the marked point and evaluate this with the patient. In this way, you can see how the device behaves during motion and how the device relates to scars, the umbilicus, and body structures. The device should be observed when filled with water. Allergic reactions to the device should be observed.
- Discuss with the patient the chosen site, so that the patient can agree with it and understands the choice.
- Mark the site definitely. Take care that the surgeon will still be able to see the marked place after disinfection has taken place.
- Do not use tattoo ink. Tattoo is a permanent marking.
- Inform the surgeon if the site is different to what would be expected. In this way, you can stop the surgeon from using the usual site and make sure the surgeon use the correct site for the patient.
2Adapted with permission from the evidence-based Stoma Care Guideline: Pre-operative site-marking, Dutch Stoma Care Nurses Society, 2006.
- Pre-operative site marking should be a standard procedure when a patient is due to undergo surgery that includes stoma formation, but also when a patient is due to undergo surgery and there is a possibility that a stoma could be performed. (LE=4, GR=C)
- Pre-operative stoma site marking must be done under the responsibility of a nurse specialist (NS), whose level of education is acceptable and who works as an NS. (LE=4, GR=C)
- The procedure described in the table above ("Siting [Site Marking] Procedure") provides the basic document for all protocols to be written in institutions. (LE=4, GR=C)
- Pre-operative assessment of the patient's manual dexterity and use of mechanical aids. (LE=4, GR=C)
Patients must have an adequate supply of products on discharge. (LE=4, GR=C)
Patient Organisations and Brochures
The nurse should be aware of national patient organisations and the availability of brochures. (LE=4, GR=C)
Optimal Timing for Learning and Practicing Skills
- Motivation and previous educational experiences are important. (LE=3, GR=C)
- A nurse needs to be sensitive to educational difficulties and be prepared to use a variety of strategies. (LE=3, GR=C)
- An NS must remember that he/she may not be able to meet all of a patient's needs and should refer on to other specialist staff where these services are available. (LE=3, GR=C)
- Patients should always have access to an NS. (LE=4, GR=C)
Procedure before and after Surgery and at Discharge
- Patients should be offered a contact number for a person living with a stoma. (LE=4, GR=C)
- Pre-operative information on stoma management should be offered, supplemented by booklets and demonstrations of relevant stoma appliances. (LE=4, GR=C)
Give a checklist of instructions how to change a stoma appliance to the patient. (LE=4, GR=C)
Discharge and Follow-up
A checklist could be useful to ensure that aspects of patients education are not overlooked. (LE=4, GR=C)
Post-operative Observation of Stoma
- Post-operative visual check of stoma to be recorded at the same time and frequency as cardiovascular observations. (LE=2b, GR=B)
- Check the temperature of the stoma through the appliance. (LE=4, GR=C)
Stoma Management by Patient and Family/Carers
Role of Family and Carers3
- Inform patients they can bring a relative to the pre-operative meeting, thereby giving the relative opportunities to ask questions and to discuss issues regarding treatment. (LE=2b, GR=B)
- Understanding of family dynamics is essential. Obtain a quick assessment of family dynamics when meeting with the client and family. Watch how the client and his or her family interact. (LE=2b, GR=B)
- Provide ostomy teaching prior to surgery. If this is not possible, begin teaching as soon as the client is alert, awake, and says their pain is under control. (LE=2b, GR=B)
- Encourage patients to participate in ostomy care as much as possible. (LE=2b, GR=B)
- Introduce new ostomy products slowly and easily. Present the patient with choices and allow him or her to decide whether any changes should be made. (LE=2b, GR=B)
3Adapted from Wong VK, White MA. Family dynamics and health locus of control in adults with ostomies. J Wound Ostomy Continence Nurs 2002;29(1):37-44.
Procedure for Discharge Care
|Table: Suggestion for Pouch-Changing Procedure
- Remove the pouch
- Inspect stoma and skin
- Wash around the stoma
- Dry around the stoma
- Eventually apply skin care products
- Competently apply a new pouch and check that is correctly sealed
- Prepare the night bag to the pouch
- Empty the pouch during the day
|Table: Topics to Be Discussed at Discharge with the Patient and Carers
- Explain the process of follow-up by the surgeon and stoma care nurse
- Provide a contact telephone number for acute problems or questions
- Explain what to do when problems occur, such as odour, urinary tract infection (UTI), leakage, etc
- Explain that mucus is normal and what to do when there is more mucus than normal
- Explain that the stoma is oedematous and swollen in the initial post-operative period and that its size will gradually reduce over 6-8 weeks
- Explain that the stoma can bleed easily on contact
- Explain the colour of normal urine, red or cloudy urine, offensive odour and the action to take
- Explain about bathing, clothing, travelling, work, hobby, sexuality, etc
- Stoma management is best learned by steps of enhancing learning. (LE=3, GR=C)
- A teaching plan will increase learning by the patient. (LE=3, GR=C)
- At discharge the nurse should discuss topics mentioned in the table above and support this with written information. (LE=3, GR=C)
Patient Control Visits/Calls
- Patient's visits to or calls by the NS start prior to surgery and for at least 3 months after hospital discharge, but preferably until 2 years after discharge. (LE=3, GR=C)
- Patients should know that specialised stoma care from a NS is available to them long term. (LE=3, GR=C)
- Patients should have a contact telephone number, together with details of their local community stoma care clinic or hospital. (LE=3, GR=C)
- Patients with specific problems should be referred to other specialist staff if these services are available. (LE=3, GR=C)
- Long-term (annual) follow up in a urological department is needed because of the high rate of urostomy-related complications. (LE=2b, GR=B)
The NS should provide the patient with a brief written history of surgery, reason for surgery, type of stoma and appliances used. (LE=4, GR=C)
Information about Possible Complication
Discharge information must be given about the common complications. (LE=4, GR=C)
Proactive and Preventive Care
Traveling with a Stoma
|Table: Patient Advice for Traveling with a Stoma
- Always take extra appliances, as a change of climate may need more frequent changes of appliance.
- Patients can obtain information on where to buy additional supplies at a travel destination from the urostomy manufacturer.
- Appliances should be kept out of the heat to prevent the adhesive melting.
- To save space, appliances can be taken out of their boxes and packed into clean plastic bags.
- Always carry appliances in the hand luggage, when traveling by air, in case checked-in luggage arrives later or disappears.
- Scissors cannot be taken through security in airports, so all appliances should be cut to fit on beforehand.
- Extra luggage (5 kg) when traveling by plane is possible. A medical letter must be provided.
The NS should give advice on travelling with a stoma. (LE=4, GR=C)
Medic Alert Bracelet, 'Can't Wait' Card, Disability Card
The NS should provide patient with a travel certificate and 'Can't Wait' card on discharge for future use. (LE=4, GR=C)
Treatment for Urinary Tract Infections (UTIs), Fluid Intake and Effect of Food on Urine
Patient education before discharge about UTI symptoms and adequate fluid intake. (LE=4, GR=C)
- Regular observation of peristomal skin to identify potential complications. (LE=4, GR=C)
- Use skin care tools for correct identification. (LE=4, GR=C)
Urine Testing from an Ileal Conduit
To collect urine for analyses catheterise the ileal loop. (LE=4, GR=C)
Parastomal Hernia (PSH)
Prevention of PSH
Support garments should be recommended post surgery. (LE=4, GR=C)
- All devices used by urostomy patients should preferably be latex free to reduce their risk of developing latex allergy because of their lifelong use of appliances. (LE=4, GR=C)
- Patients must also know that if they have an allergic reaction, it could be an allergic reaction to latex. (LE=4, GR=C)
Refer to the original guideline for a discussion of types of urostomy appliances (bags) and other urostomy products (barrier strips/rings, pastes, belts, and binders).
Skin Care Products
Skin Barriers (Second Skin)
Use a silicone based product in all patients who require a skin barrier. (LE=4, GR=C)
Karaya Moisture Absorber
Use Karaya moisture absorber or a similar powder in patients with appliance adhesion problems or follow local policy. (LE=4, GR=C)
Complications and Problems of Having a Urostoma (Urostomy)
- A stoma nurse should collect data related to the skin, such as underlying skin diseases or immunological disorders, as part of the pre-operative assessment of the peristomal skin. (LE=4, GR=C)
- To prevent skin irritation from failure of the pouching system, due to a poorly sited stoma, the stoma site should be marked out prior to surgery by a stoma (or Wound, Ostomy and Continence) nurse. (LE=4, GR=C)
- To prevent skin irritation, the Guidelines Group recommends cleaning of the peristomal skin using warm water and gently drying with gauze. Men should be shown how to shave peristomal hair without damaging the skin and moving outwards away from the stoma. (LE=4, GR=C)
- To prevent skin irritation the patient should be taught to cut the barrier, so that the opening just fits the size of the stoma. This will minimise the risk of urine coming into contact with the peristomal skin. It is important to tell the patient that the stoma will decrease in size for at least 8 weeks after surgery and that the size of the opening of the barrier must also change. (LE=4, GR=C)
- When treating skin irritation, it is important to assess the aetiology. A skin barrier that resists urine erosion can be used. (LE=4, GR=C)
Patients with a leakage problem should be advised to consult a stoma care nurse for solving the problem. (LE=4, GR=C)
Urinary Tract Infections (UTIs)
No treatment for asymptomatic bacteriuria, unless there is a history of recurrent pyelonephritis (asymptomatic bacteriuria: presence of bacteria in urine without symptoms). (LE=2b, GR=B)
Complications Caused by Significant Variation in pH of Urine
The following are recommended for acid urine (LE=2b)
- An 'acid-ish' diet – a diet high in animal protein, which includes butter, cheese, fats, and lentils
- Decreased intake of citrus fruits (orange juice!)
- Ammonium chloride as the preferable urinary acidifier
UTI, Mucus and Stones Formation: Use of Cranberry
Cranberry can be advised in daily practice when patients have complaints of (symptomatic) UTI and/or excess mucus, and/or skin problems, and/or leakage problems. (LE=4, GR=C)
Refer to the original guideline document for further discussion of physical problems associated with urostomy, including retraction, mucus production, granuloma, stomal bleeding and ulceration, and purple bag syndrome.
Psychological and Social Problems
Refer to the original guideline document for a discussion of postoperative social considerations as well as cultural and psychological aspects of care.
Sexual Dysfunction in Males
Treatment of Erectile Dysfunction
Male patients with post-operative erectile dysfunction should be assessed for suitability for treatment if requested. (LE=4, GR=C)
Sexual Dysfunction in Females
- Radical pelvic surgery need not mean the end of an active sex life for either men or women. Restoration of sexual activity may, however, require further treatment, a certain degree of adaptability and specialist intervention. (LE=4, LE=C)
- Patients should be advised pre-operatively of potential alterations to their pre-surgical sexual function. (LE=4, GR=C)
- Post-operative counselling should include discussion of treatment options and their suitability for individual patients. (LE=4, GR=C)
Levels of Evidence (LE)
1a Evidence obtained from meta-analysis of randomized trials
1b Evidence obtained from at least one randomized trial
2a Evidence obtained from one well-designed controlled study without randomization
2b Evidence obtained from at least one other type of well-designed quasi-experimental study
3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports
4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities
Grades of Recommendation (GR)
- Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
- Based on well-conducted clinical studies, but without randomized clinical trials
- Made despite the absence of directly applicable clinical studies of good quality