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Utskriftsdato (20.9.2017)

Life with a stoma


Medical editor Birgit Sunde
Stoma Nurse
Oslo University Hospital

General

A stoma changes lifestyle to different degrees as well as to body image, and practical and emotional questions will arise associated with this.

A stoma is seldom a hindrance to resuming social life, but requires time to become accustomed to the change in bodily functions. Most can continue with recreational activities and work as before.

The patient should obtain training in stoma maintenance and hygiene during the first days after the operation. The patient should quickly start maintenance of the stoma.

Indication

  • Sigmoideostomy
  • Transversostomy
  • Ileostomy

Goal

  • Live comfortably with a stoma

Equipment

  • Stoma disc and pouch  
  • Unsterile compresser
  • Water
  • Stoma template
  • Pen
  • Scissors
  • Barrier cream
  • Waste pouch

Remedies

Barrier cream is a special cream intended for the skin around the stoma.The cream increases moisture and strengthens the skin. It contains little oil in order for the stoma to attach to the skin. The cream should be spread in a thin layer and excess cream should be wiped away after a few minutes for optimal attachment of the stoma disc.

Barrier film is found as a spray or applicator and lies as a membrane on the skin as a protectant from bowel content.

Stoma powder is used when the skin is sore and moist. The powder is sprinkled on moist areas and absorbs the moisture in order for the disc to attach itself. Powder on dry skin is blown away as this will reduce the adherence of the disc.

Paste and gaskets allow for tighter bandaging where the skin around the stoma is uneven. Gasket paste contains alcohol and burns where the skin is sore. This can be avoided by sprinkling stoma powder on the skin first.

Crystal violet 0.5% is a dye with antibacterial and antifungal properties. It will also dry out moist skin. The substance is spread with a cotton ball and allowed to air dry before a new skin disc is applied.

Hydrocortisone cream 0.1% can also be applied to sore skin. The cream in an anti-inflammatory and should not be used more than 14 days in a row. The cream is massaged into the skin. Excess cream should be dried after a few minutes for optimal adherance of the stoma disc.


Preparation

When the patient is ready to carry out stoma changes, the situation should be as close to their home situation as possible. The patient can choose to sit or stand and it is recommended to carry out the change in front of a sink with running, temperate water. It is helpful to have extra room for equipment within reach.

A bag for waste is attached to the trouser waistband to catch bowel content when the disc and pouch are removed.

It may be appropriate to shave the area where the stoma disc will be attached for better adherence.

Challenges regarding odor are greatest immediately following surgery. It is therefore recommended to change the bag in a well-ventilated room and/or to use a fan.


Implementation

Stoma care

  • To avoid spillage on clothing and to collect used equipment, the waste bag is attached to the waistband.
  • The stoma disc is loosened with a moist compress and carefully removed.
  • The skin and stoma are carefully washed with a lukewarm compress before it is dried/air dried/blown dry. It is the normal for the the stoma to bleed when touched.
  • Red, dry skin can be moistened with barrier cream in a thin layer. The cream should absorb into the skin for a few minutes before excess cream is dried away such that the disc will adhere to the skin.
  • The stoma template is cut out of cardboard or colorless, stiff plastic to the size of the stoma . A caliper can be used for measurement .
  • The stoma template is placed on the back of the new adherence disc and traced before adherence disc is cut and threaded over the stoma. Check that it sits properly on the skin.
  • A one component bandage consists of a complete bag with adhesive surface . The one component closed back is changed after every bag change which is usually 2-3 times a day. A one component reusable bag is changed daily or every other day.
  • A two component bandage consists of s skin disc and bag in two parts . The bag is threaded over the stoma and attached to the disc. The disc is usually changed 2-3 times per week. The closed, reusable bag is changed like a one component bandage and changed as needed.

For a small intestine stoma, it is recommended to change the bag before breakfast because the bowel content comes almost immediately after the patient has eaten.

Irrigation

Irrigation is an alternative to a skin disc and back and is used in patients with a colostomy. The advantage of irrigating is that in between, there is little feces and bowel gases and the risk for odor and sound is less. Irrigation is time consuming (about one hour) which should be done every other day. Most patients therefore recommend using stoma bags.

  • A water holder with water regulation and an irrigation bag is required.
  • The colon is emptied by regular insertion of water enema.
  • The bowel is emptied every other day by using around 800-900 ml of body temperature spring water set via the stoma and in the bowel.
  • The stoma is bandaged in the end with a mini bag or Mini Cap with air filter with little/no space for bowel content.
  • At the Radium Hospital, stoma nurses are reponsible for training the patients in the technique.

Follow-up

Upon discharge from the hospital, the patient obtains stoma supplies for about 4 weeks. The patient should be checked regularly at a stoma clinic or by nurse or doctor in their home town.  Stoma patients need follow-up to assist with practical and emotional challenges.

Stoma supplies can be obtained from a surgical store or pharmacy as a "blue prescription" § 3.1 in one year intervals. The equipment is specified on a stoma bandage card which is attached to the prescription. It is common to obtain equipment for a 3 month period. The patient should pay a copayment until they have a "free-card."

Daily life

A stoma itself is not a hindrance in the workplace or in daily life. For air travel, stoma equipment should be stored in hand luggage. Stoma equipment cannot be purchased on a "blue prescription" outside Norway. A shower can be taken with or without the bag. Bathing can done with the bag if the filter is covered. Tight clothing and waistbands which might squeeze the bag such that it does not fill properly should be avoided.

Sexuality

A stoma itself is not a hindrance for a normal sexual relations. Lack of energy and changes in body image after surgery may require time before sexual desire resumes. This will happen more quickly if partners are open about their relationship where both are able to express feelings and needs and have consideration for each other. If sexual relations become more difficult to master, it might be beneficial to seek professional help.

Special conditions for females

For stoma operated females who have removed the colon or rectum, the uterus can lean to the back in the empty space. The vagina can also be bent where a pocket can form in which discharge collects. The pocket is emptied by changing body position. It is helpful to rinse the vagina regularly with water containing a small amount of yogurt or a tablespoon of vinegar to one liter of water. This can be added to a an ear rinsing balloon which is obtained at a pharmacy.

A bentover uterus may cause pain and during intercourse but can be avoided by choosing positions in which the female is not on her back. If the operation after cancer treatment has lead to nerve damage, reduced feeling and discomfort from vaginal dryness may occur. Lubrication jelly will help this.

A stoma is not a hindrance for pregnancy and birth. Before the stoma is installed, the woman should discuss prevention and sterilization with her doctor and whether she plans on having children. The doctor can then take the necessary precautions.

Special conditions for males

The nerves in the groin area may be damaged during cancer treatment and surgery. This can lead to impotence and ineffective ejaculation. There are measures for impotence which may also be psychological and resume after time. It is important the patient is informed about this before the operation.

Nutrition

It is usually not necessary to change eating habits. It may be appropriate to resume the eating habits the patient had prior to surgery. Food that is tolerated is very individual and it is also necessary to try different foods. It is recommended to eat 4 medium-size meals a day. If one does not prefer to eat enough at each mealtime then snacks are recommended. Irregular mealtimes can cause irregular bowel motions and gas.  General advice is to chew food well, take time for meals, and drink at least two liters of water per day.  Food should have a low fat content and moderate amounts of fiber. Regular exercise with relaxation after mealtimes is recommended.

Food which can cause constipation/ileus

Nuts, fibrous foods such as asparagus, oranges, celery, seeded grapes, prunes, mushrooms, popcorn and corn shells, and fruit skin can cause constipation.

Food which can cause gas

Carbonated beverages, cabbage, onions, beans, sorbitol (artificial sweetener), chewing gum, and spicy foods can cause gas. Tea, caraway, fennel seed, and blanching of cabbage vegetables before boiling as well as physical exercise at a moderate tempo can be preventative. The pharmacy has over-the-counter products to prevent gas from accumulating.

Foods which can cause thin stool

Dried fruit, orange juice, pears, cherries, plumbs, hermetic fruit, alcohol, sorbitol, aspartame, sugar in large quantities, and fatty foods can cause diarrhea. Ripe bananas, blueberries, boiled potatoes, carrot puree, apple sauce, apple juice, pasta, rice, boiled milk, and peanut butter have the opposite effect. The pharmacy has over-the-counter products which improve the absorbance function of the bowel and can be taken in prevention and regularly.

General advice for ileostomy operated patients

Food can be salted extra due to loss of electrolytes through bowel movements. Food with a high fiber content should be chewed well to ease digestion and hinder enteralgia. It is recommended to take vitamin B12 due a lack of nutrient absorption in the lower part of the small intestine. Electrolyte mixtures are available at the pharmacy. Sport drinks can be taken used an alternative.