Lessons 35-36: Rehab For The Ostomy Patient

Question 1

Potential Impacts on Quality of Life

Answer 1

• Alterations in body function and appearance
• Loss of sphincter + modified continence
• Initial adjustment is major challenge
• Trauma causes increased anxiety +/- period of emotional numbness

Question 2

Factors Impacting Coping Skills

Answer 2

• Preoperative personality and coping skills
• reason for surgery
• patient expectations about impact of stoma
• response of family and friends
• cultural issues
• development stage of patient
• what help is available to the patient
• access to an ostomy visitor/peer support

Question 3

Questions to ask preop

Answer 3

• What are your biggest concerns about having an ostomy
• Have you been able to talk about the ostomy with you significant other?
• How do they feel about it?
• Are you concerned about the potential impact on your relationship?
• What do you think you’ll be doing in 3-6 months?

Question 4

Questions to ask postop

Answer 4

• How are you doing/feeling?
• Who is emptying/changing the pouch?
• What problems are you having related to the ostomy?
• How are you doing in returning to your usual activities?
• Are you in touch with any support groups?
• How can I help you?

Question 5

Indications of Self-Mastery

Answer 5

• Pouch management
• Pouch change procedure
• Management of peristomal skin breakdown
• When and how to obtain supplies
• Community resources
• Prevent and management of complications

Question 6

Adaptation Process

Answer 6

1) Shock, panic, disbelief
2) Denial
3) Acknowledgement, anger, and depression
4) Adaptation + resolution

Question 7

Adaption Process - Shock, Panic, and Disbelief

Answer 7

• Response to news that threatens sense of security
• Hysterical or mechanical behavior
• Best intervention is supportive care

Question 8

Adaptation Process - Denial

Answer 8

• Manages the threat by denying/minimizing its existence
• “Morphine for the soul”
• Preop
  — Patient believe they won’t need the stoma
• Postop
  — May ignore stoma
  — Refuse to look/refuse self-care
  — Focused on ostomy takedown/reversal
• Interventions
  — Avoid direct challenge
  — Focus on informed consent
  — Use gentle confrontation to help direct focus on discharge

Question 9

Adaptation Process - Acknowledgement, anger, and depression

Answer 9

• Patient begins to actively deal with their feelings
• Common behaviors
  — Anger (irritability, hostility)
  — Sadness (withdrawn, crying, negative statements)
  — Acting out (wearing pouch outside clothing)
• Interventions
  — Supportive listening
  — Reassure negative feelings subside over 3-6 months
  — Encourage patient to grieve openly
  — Gentle confrontation for “acting out”

Question 10

Adaptation Process - Adaptation + resolution

Answer 10

• Acute grief subsides
• Focus shifts to mastery of self-care and moving forward
• Patient asks lots of questions

Interventions
- Teaching
- Problem solving
- Basic counseling
- Referral to support groups

Question 11

Primary Concerns for Ostomy Patient

Answer 11

• Self care
• Pouch leakage/odor/noise/embarrassment
• Clothing issues
• Dating + sexual concerns
• Sports/travel/leisure
• Body image/ “feeling dirty”
• Cost of supplies

Question 12

Role of the Ostomy Nurse

Answer 12

• Gently encourage and push patient
• Establishment of secure pouching system
• Ongoing assessment of progress in adaption
• Education in self care and ostomy management
• Supportive counseling/support group referral

Question 13

Principles/Guidelines for Effective Education

Answer 13

• assess the patient’s readiness to learn
• Delay Teaching when patient is upset or in physical distress
• Focus initial teaching on survival skills
• Avoid information overload
• Keep instructions as simple as possible
• Plan for repetition
• Use of multiple teaching and learning strategies
• Use demo + return to teach skills
• Constantly evaluate patient’s learning
• Assure home health and outpatient followup
• Select appropriate teaching materials
  — 5th grade reading leave
  — 14pt font
  — Simple layout

Question 14

Teaching Based on Developmental Stage - Infants

Answer 14

• Teach parents with above guidelines
• Suggest clothing modifications to maintain pouch seal
• Provide support to parents in baby’s health adaptations

Question 15

Teaching Based on Developmental Stage - Toddlers/Preschool

Answer 15

• Pouching modifications to address increasing activity levels
• Play therapy
• School age children should begin participating in care

Question 16

Teaching Based on Developmental Stage - Geriatrics

Answer 16

• Shorter, more frequent sessions
• Written materials in large, dark font
• Simplify procedures and instructions
• Product considerations
  — Consider dexterity and hand/eye coordination issues
  — Cost issues

Question 17

Supportive Counselling

Answer 17

• Ask patient how ostomy is impacting their life with specific problems
• Listen to the patient - focus on truly hearing them
• Acknowledge patient’s physical and emotional pain
• Provide honest feedback and help patient maintain perspective
• Discuss normal emotional response and usual time frame for feeling better

Question 18

Depression

Answer 18

Indicators
- Frequent crying
- Consistent withdrawal
- Negativity
- Loss of appetite
- Sleep disturbances
- Inability to concentrate

Need to screen
- Have you felt down or depressed over the last 2 weeks?
- Have you felt pleasure in doing things over the last 2 weeks?
- Screening tools
— Beck Depression Inventory
— Geriatric Depression Scale
- Suicidal thoughts?

Mild depression
- Acknowledge feelings of sadness are normal
- Encourage to discuss feelings openly
- Encourage to set goals + focus on accomplishments
- Encourage to challenge negative thoughts
- Assist to maintain perspective

Question 19

Anxiety

Answer 19

Indicators
- Excessive worry
- Preoccupation with ostomy

Assessment
- Gentle confirmation and open discussion
- Differentiate between normal nervousness and severe anxiety
— Does it preclude participation in activities?

Severe anxiety
- Preventing patient from progressing/participating in usual activities
- Referral to psych for medications and therapy

Question 20

Frustration

Answer 20

Irritability and anger over small problems

Interventions
- Encourage patient to identify what is frustrating
- Acknowledge this is difficult and frustrating time
— Trying to master a new skill while not feeling well isn’t easy
- Encourage patient to vent feelings honestly

Ask: “Is there anything I can do to make things better?”