What might your ostomy-related goals be in in-patient rehab?

In in-patient rehab, stays may be short. When, as a nurse or therapist, you have a client with a new ostomy, it is easy for goal-setting in this area to be overlooked. Trained wound and ostomy staff (WOCN: Wound, Ostomy and Continence Nurse) are not always available in every setting. Nevertheless, each interaction with members of staff (nursing, therapy, medicine), are both opportunities for teaching, and opportunities to normalize and accept the situation for the person with ostomy.

This article is filled with resources, video links, reference guides that you can use and provide to your patient! Here, we also go through five goals that you, as a clinician, should be setting or considering, when your client has an ostomy. We also take you, step-wise, through how you can break down and meet this goal- which is extremely handy if ostomy care is not something you are doing on a daily basis!       

Through reading and understanding these goals, you can get a basic understanding of how to manage an ostomy- and how to help your patient manage it, too!

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Setting goals for ostomy care

Depending on the patient’s situation, you will be setting varying goals. If their caregiver is likely to manage their ostomy, you can change the verbiage to reflect this. If the patient is capable of managing their ostomy themselves, then it is incredibly important that they are independent with this before returning to home.

Knowing where to access supplies and ongoing education is also going to be important. Support, community resources, advocacy will be part of your patient’s ongoing life with an ostomy, and increase their self-efficacy and esteem. Provide them with support from the outset and they will be set up for success!

How to write ostomy goals in rehab

Protocol for each goal:

Patient should able to:

1. Teach back the terms related to the ostomy and the correct names of the supplies used
   • Explain what an ostomy is, and point to the various body parts in consideration. Use simple terms: an ostomy is a surgical procedure, creating an opening for stool or urine to be excreted; a stoma can refer to the opening on your abdomen, or the flat or protruding part of the visible intestine; ostomies are defined by their location- such as a colostomy, which opens the colon, ileostomy at the ileum, and urostomy at the bladder.
     • Have a nearby reference sheet that you can use, and that your client can refer back to
     • Bring up some appropriate videos on their device (if used) before you leave
   • Encourage person to touch and explore the area surrounding and the stoma. This can help them learn about what the various areas are called, and the tactile cues can aid in understanding. The stoma should not feel sore or tender- it does not have any sensitive nerve tissue. Becoming comfortable with this newly visible part of their body can go a long way toward confidence when it comes to changing their pouch.
   • Show and demonstrate the various ostomy supplies, verbalize and have person repeat
     • Have a reference guide nearby that you can use, with the specific type of supplies you are using
2. Perform adequate skin care and teach back infection reduction techniques
   • Discuss risks for skin breakdown
     • Improper application of the pouching system will be the main issue contributing to skin breakdown. Teach your patient to properly clean and protect the skin around their stoma; change immediately with a  leak; monitor for adhesive sensitivities; be gentle and methodical with ouch removal to avoid skin tears; and perhaps even working with a nutritionist to identify foods that are irritable to the digestive system. Be sure your patient knows these risks and is carefully monitoring for them
   • Work with the team. Ensure that a nurse, even if not a WOCN, is advising on skin issues and protection.
   • Discuss risks for infection. Excessive moisture, poor hygiene, irregular changing of the pouch, or a poor technique can all contribute to infections or increase the risks
     • Fungal infections can be a risk factor, especially for those with diabetes, anemia, lowered immune systems, or those taking antibiotics
     • Folliculitis can be an issue if a hair follicle becomes inflamed (a client may not have shaved the area around the seal), and may also lead to a fungal infection
     • Dermal openings can become inflamed and infected if skin tears occur- gently removing the pouch and using ‘crusting’ techniques can offset this issue in those with fragile skin (Check out this video on how to use this skill)
3. Verbalize how often the ostomy should be emptied and changed; be independent with emptying ostomy
   • Explain why and how often emptying and changing should occur; this will vary depending on the location of the ostomy. A colostomy may require pouch emptying only 2-3 times a day, whereas an ileostomy or urostomy may require emptying 6-8 times a day.
   • An ostomy should be changed when it is less than half full. Generally about two hours after eating/drinking, before activity, showering, bedtime, etc. should be when the ostomy bag is emptied. Depending on the location of the ostomy, your client may expect more or less output (with higher in the digestive tract creating more output).
     • Write on whiteboard or visual planner that person uses, or help them set timed reminders
     • Refer them to a reference guide/video to help them understand the process.
   • Ensure your person can handle the ostomy
     • Think about the skills required to manage an ostomy. Fine motor control and coordination, hand strength, balance (sitting or standing) and cognition. Modifications can be made to ensure your person is as independent as they can be with this new skill.
     • Consider practicing opening, closing, emptying, and changing with and empty pouch and clean supplies, in order to build confidence and really understand the process
   • Ensure they can get up close to the toilet
     • Empty directly into toilet. In many in-patient facilities, ostomies may be emptied into a receptacle, but this does not prepare the person for return to function in the community; and is not a sanitary option outside of the person’s own environment.
       • It is also key to consider strategies for emptying that work in public settings, as well as the home. You may only work with your client for a short time- but if they do not have a toileting routine that will work outside of the home, it can impede their return to the community. This is a key role in early rehab.
       • Drop some toilet paper into toilet to prevent splashback. Sitting on the toilet (facing either direction), kneeling, squatting, or standing over the toilet may be a skill you will need to think about with your person
     • Clean the ends of the outlet and close
   • Discuss and demonstrate ‘burping’ ostomy
     • Ideally, the filter manages excess gas build-up- but may be clogged or just may not work
     • Burping will release excess gas built up through the outlet at the bottom or through the opening at the top
4. Be independent with changing pouch
   • Practice with empty or clean supplies if able, to build confidence
   • Discuss different places it can be changed: in shower, by sink, in front of mirror; changes every 3-7 days depending on type of stoma, personal preference, type of pouch.
   • Practice collecting and making sure all supplies are to hand
     • Measuring guide, wet paper towels, wash cloths, dry towel, scissors, pouch system being used (1 or 2 piece), stoma powder, paste.
   • Remove the pouch by gently pressing down on the skin with moist/wet towels, lifting the corner. Collect any stool/urine in old pouch.
   • Skin checks when pouch is removed- skin cleanse with water only and dried completely. Crusting or other skin care techniques can be completed at this point
   • Stoma measurement to ensure no change in size and to cut a hole matching the size of the stoma (1 piece system) or the flange attaching to the bag (2-piece system) Watch these videos for more information of how to change the ostomy bag!
     • Provide your patient with extensive reference guides and videos depending on type of ostomy supplies they will be using
5. Recognize resources available to them
   • Professional support: Even if there is not access to a WOCN in your facility, some ostomy appliance manufacturers have consulting WOCNs available by phone. This can be a useful resource to those who may need some discussion, tips, or input
   • Ostomy systems: There are hundreds of variations of pouches and systems, and many products for skin protection and care. Different systems also make a difference in terms of fine motor demands, visual demands, ad even abdominal muscle tone. People who may be experiencing difficulty should know that if one system is not working as well as they would hope, or if they are having ongoing issues, that another system may work for them. Consulting WOCNs at ostomy appliance manufacturers may provide sample systems for trial use
   • Online support: Exchanging experiences, reading and watching videos from some great online experts may help your client to realize what is ‘normal’ for them in this situation- and what is not working. They may incorrectly believe that a wear time is shorter than it should be, or that the amount of burping/changing is to be expected, when they may instead require input into the supplies they are using.
6. Be engaged in psychological acceptance and counseling
   • Talk to them about living with ostomy: does not limit engagement in activity
     • Odor management – this is a huge worry for people, however there should be no odor when the pouch is attached correctly
     • Natural process- you can assure your person that there will be an odor experienced when burping, emptying or changing the pouch, but that there is a smell attached to anyone’s bowel movements. Encourage them to see this as a natural process of elimination, albeit mechanically aided on their part
     • They will be able to function in anything they would want to with an ostomy- an ostomy shouldn’t limit any activity they wish to pursue
   • Dealing with other emotional complications that may have brought them to the point of ostomy (CA, illness, grief/anger, body acceptance/self-esteem)
   • Encourage touch and exploration- this will be very importance for self-esteem and bodily acceptance. Some people will not want to engage with their ostomy or stoma whatsoever, but this will prolong the pain and grief they are experiencing
   • Remind them of their strength. Whatever got them to this point could not have been easy… yet here they are! Remind them of the strength they have already shown and continue to show as they live with this ‘new normal’
   • Do not be afraid to bring up return to activity- especially hobbies, things they love to do, and sexuality. Waiting for your person to bring it up may be too embarrassing for them! You can also wear a badge or a pin that says- ‘ask me anything about your ostomy’, or similar
   • Support groups online and in-person. Set them up with online groups and connect them with others- as above, don’t wait to give them the supports they need and may be craving

Including appropriate goals for ostomy care and management is crucial in an in-patient (or, really any, setting). Unfortunately, many in-patient clinicians do not see this as part of their more conventional rehab goals- and so, it can be passed over or ignored. Breaking down the needs that your client has: increased understanding, independence with self-care, skin protection, etc… and setting the appropriate, step-by-step goals can help to bridge some of the intimidation around this sensitive area.

I hope that seeing some of these ‘ready-made’ goals can help you to become more confident around ostomy care, and in including it as part of your therapy or nursing plan!

Are you are interested in upskilling your practice? Check out ‘A Comprehensive Guide to Wound Care: Tools for the Everyday Clinician‘! This engaging and super-practical seminar will give you the hands-on skills and the confidence you need to be able to assess and manage all types of wounds. Now available live or virtually!

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