Clinical Nurse Specialists Stoma Care

8/7/2019 Clinical Nurse Specialists Stoma Care

1/24

Clinical nurse specialistsStoma care


2/24

2 Clinical nurse specialists Stoma care

Acknowledgements

With thanks to all who contributed, the ScottishStoma Care Nurse Specialist Group, the RCN andmembers o the working party:

Elaine Macleod Clinical Nurse Specialist Stoma Care,Southern General Hospital, Glasgow

Nancy Johnstone Clinical Nurse Specialist StomaCare, Ayr Hospital, Ayr

Isabell Robertson Clinical Nurse Specialist StomaCare, Monklands Hospital, Airdrie

David Lawson Clinical Nurse Specialist Stoma Care,Western General Hospital, Edinburgh

2009 Royal College o Nursing. All rights reserved. Other than as permitted by law no part o this publication may be reproduced,stored in a retrieval system, or transmitted in any orm or by any means electronic, mechanical, photocopying, recording or otherwise,without prior permission o the Publishers or a licence permitting restricted copying issued by the Copyright Licensing Agency, SaronHouse, 6-10 Kirby Street, London EC1N 8TS. This publication may not be lent, resold, hired out or otherwise disposed o by ways otrade in any orm o binding or cover other than that in which it is published, without the prior consent o the Publishers.


3/24

3

Foreword 5

Introduction 6

Clinical nurse specialists 9

A day in the lie o a CNS 9

The CNS stoma care role 10

Clinical 10

A day in the lie o a CNS 12

Patient story 13

Education 15Patient comments 16

Research and audit 16

Consultancy 18

Consultancy in action 18

Management 19

Consultancy in action 19

Summary 21

Patient story 21

References and further reading 22

Contents


4/24



5/24

5

Stoma nurse specialistsare pathnders whohelp guide patients ontheir journey to a newlie that should be reerom disease and o abetter quality. However,adapting to lie witha stoma involves anumber o physical and

psychological challenges, and the partnership ormedbetween a patient and a stoma nurse specialist iscentral to making this transition a successul one.

Stoma care patients ace a number o issues, many o

which are still considered taboo and which can leadto embarrassment and distress. They rely on stomanurse specialists to resolve these issues eectively,provide support and guidance on a broad range opractical issues such as stoma management andpersonal nutrition, and contribute to improved socialand personal condence levels.

Many stoma patients are independent people whohave experienced serious illness and long complextreatments. Making the transition back to normality a world where they must maintain and createrelationships, care or others and support themselvesnancially can seem a daunting prospect andrequires great ortitude.

Any ailure on the journey to achieving an eective

return to normal lie may make the treatment andits long term consequences, particularly the stoma,seem worse than the original illness. The stomanurse specialist thereore plays a key role in the

rehabilitation process, by providing inormation,education, as well as encouragement and counsellingor patients and their carers, all o whom have adiverse range o ears, needs and aspirations.

Patients have stomas created as part o treatmentor a wide spectrum o diseases including cancer,

chronic infammatory disease and incontinence.Stoma nurse specialists also support patients withincurable disease, where only palliation is possible.Consequently, stoma nurse specialists need a broadknowledge base, and must be capable o workingwithin the diverse clinical teams that give support tothese vulnerable patients.

Stoma nurse specialists were the rst clinical group

to establish widespread, independent, sub-specialistskills in gastroenterology and urology; a modelwhich is now widely ollowed by doctors and othernurses. As a clinical group they were also one othe rst to recognise the importance o a patientsquality o lie, both in terms o treatment planningand the measurement o treatment outcomes. Theyare ounder members o the multidisciplinary teamswhich today provide increasingly complex care topatients.

The comprehensive holistic care provided by stomacare nurse specialists has become central to enablingstoma patients achieve a successul recovery andrehabilitation ater a major illness.

R H Diament

Lead Clinician, West o Scotland Managed ClinicalNetwork or Colorectal Cancer

Foreword


6/24


Introduction

Serious conditions o the bowel and bladder canaect people o any age, rom babies throughto the elderly. The surgical treatment o theseconditions which include bowel and bladder cancer,infammatory bowel disease and diverticulosis,unctional problems or trauma oten requires theormation o a stoma.

A stoma is an articial opening on the abdomen todivert the fow o aeces or urine into an externalpouch located outside o the body. This proceduremay be temporary or permanent. It is estimated thatthere are 100,000 people in the UK with a stoma(Williams and Ebanks, 2003).

There are three basic types of stoma:

colostomyanopeningintothelargebowel(colon), usually sited on the lower let side o theabdomen; a transverse colostomy, which is sitedabove the waist, can be on the let or right side

ileostomyanopeningintotheileum(small intestine), usually sited on the right lowerside o the abdomen

urostomyanopeningintotheurinarytract

and usually sited on the right lower side o theabdomen.

Stoma ormation will have an impact on the wellbeingand liestyle o the person and their amily whatevertheir age (Waller, 2008). Quality o lie can deteriorateollowing a stoma procedure and specialist supportduring the rst ew weeks post-stoma is vital. Fear

o rejection by riends and amily as well as beingostracized by society is constant or this group opatients (Williams, 2008). The stoma nurse specialisthas a key role in oering patients reassurance,

support and guidance on how best to manage allthese issues and how to manage their stoma around

their activities o daily living in order or them toachieve a successul rehabilitation.

Having a stoma is a major event, and can lead topatients becoming very anxious and depressed.Whats more, stoma surgery oten has a huge impacton body image and personal relationships can suer.Patients need reassurance, support and guidanceon how best to manage all these issues and how

to manage their stoma around their day-to-dayactivities, in order to review or achieve acceptablequality o lie.


7/24

7


8/24



9/24

9

Clinical nurse specialists

There have been clinical nurse specialists (CNS) in

stoma care since the early 1970s, when it becameevident that patients undergoing a stoma procedureneeded extra support to help them through the verychallenging journey back to living a normal lie.

The impact o this surgery can be overwhelming,causing distress, ear and eelings o hopelessness.It can take up to two years or some individuals to

come to terms with the way they look and unction

and to acquire a positive sel image; others may neverachieve this stage (Dryden, 2003). The role o the CNS

in stoma care is to support patients, using specialistknowledge and skills to enhance their quality o lie.In this respect, the stoma care service is a recognisedinvaluable resource:

Access to a stoma nurse specialist increases patient

satisaction and optimal independent unctioning.

Clinical Standards Board or Scotland, 2001

A day in the life of a CNS

A day in the life of Jackie Macleod,Clinical Nurse Specialist

I am based in Raigmore Hospital, Inverness wherethere is a team o three ull time CNS in stoma care

and colorectal surgery. Today I will start in the wardsbeore heading to Fort William a round trip o 128miles or my nurse-led clinic and teaching sessionwith district nurses.

In the hospital I review a patient who had emergencysurgery yesterday resulting in the ormation o astoma, and a lady who has been extremely anxious

ater bowel cancer surgery. Ater support andencouragement this lady is now managing her careand is due or discharge soon. I review anotherpatient who has had an ileostomy as a result o anischaemic bowel. Her weight loss has contributedto the delay o her wound healing, and diculties inapplying the bag. The visit requires time with the stato ensure they are aware o the complexities o stoma

care and the psychological support needs or thispatient. Finally, I give advice regarding diet, exercise,and liestyle issues to a patient who is scheduledor discharge.

I head to Fort William where I discuss troubleshootingproblem stomas with the district nurses, looking atdierent types o bags and accessories, which canoten give solutions.

My colleague phones to reer a patient who has

sore skin around her stoma. I arrange to visit on myway back to Inverness, as she lives not ar rom FortWilliam. Patients and amilies in these remote placesare extremely grateul to have these visits, as it givesthem time to discuss issues they may have orgottenor were too embarrassed to ask about whilst inhospital.

Four patients in the clinic have come along or general

support and advice and the opportunity to see newproducts. Typical issues or concerns brought up bypatients include sore skin, ear o bag leakage, andworries about planning a holiday, or their relationshipwith their partner.

Clinic over, I head or Inverness with a quick visit enroute. The patients stoma has changed size, causing

sore skin. I order dierent bags or her to resolve this.I will telephone the district nurse with an update andcall the patient next week or a progress report.


10/24


The CNS stoma care role

A CNS in stoma care is a registered nursingproessional working within the NHS who hasacquired additional knowledge, skills and experiencetogether with an academically accredited postregistration qualication. These specialists practice atan advanced level, and work autonomously to delivera high standard o care. The role o the CNS in stomacare is complex and challenging, as well as rewarding.

The key aspects o the role are clinical, education,research and audit, consultancy, and management(Rust, 2009, Humphris,1994).

Clinical

The CNS in stoma care provides a specialist serviceor patients o all age groups, as well as their relatives

and carers. Inormation and support is delivered priorto surgery, during the patients hospital stay, andollowing discharge into the community.

This will encompass:

pre-operativeassessmentforpatientsundergoingelective surgery

pre-operativeassessmentforpatientsinhospitalor emergency surgery

specialistnursingcareduringthehospitalstay,and continuing support to patients and amily

educationandliaisonwithallhealthcareproessionals involved in the care o the stomapatient

developmentofacomprehensiveandexibledischarge plan with hospital and community healthproessionals

ongoingsupporttopatientandfamilyandspecialist back-up or community health care

proessionals availabilitytoallstomapatients(newand

established) and their amilies to provide supportand advice when necessary.

Throughout the lie-changing experience o having astoma, the care provided by the CNS will encompassnot only the physical but the psychological, spiritual,

cultural, sexual and social needs o the individual.In its publication Guidelines or the managemento colorectal cancer(2007) the Association oColoproctology o Great Britain and Irelandemphasises the vital role played by the CNS instoma care:

The patient should be seen by a stoma nurse prior

to surgery and the reerral should be made at theearliest opportunity to allow adequate time or

preparation.

In its colorectal cancer guidelines (2003), the ScottishIntercollegiate Guideline Network also states:

Patients with colorectal cancer who require stoma

ormation generally experience more problems thanthose who do not and the support and advice o a

stoma nurse specialist is widely acknowledged to be

o considerable value.


11/24

11

li i l i li


12/24

12

A day in the life of a CNS

Fiona Winslow, a Glasgow-based CNS,

gives an insight into a typical day

I lead the stoma care service at the Western Inrmaryand Gartnavel General Hospital and also at TheBeatson, the West o Scotlands regional cancercentre. The day begins answering messages andchecking or any new patients. All in patients withinthe various wards are visited. I am inormed o a

patient at the Western who is to have emergencysurgery today. I travel to the Western Inrmary andhave a brie chat with the lady going to theatre. Shedoes not eel up to receiving much in the way oinormation but is keen to see what a bag looks likeand know how the stoma will work. I mark the siteor the stoma, which is dicult due to her swollenabdomen. Im inormed o a patient who had an

emergency colostomy during the night due to trauma.I chat with him, check his stoma and supply bags orhim as well as literature to read. I attend the multi-disciplinary team meeting in the Beatson, whereall patients having undergone or about to undergosurgery or colorectal cancer are discussed.

A 28 year old is struggling to cope with his stoma andhis mother has contacted me to request a review as

she is concerned about him; I call and arrange to meetwith him. A patient who had a urostomy a couple oyears ago telephones. Practically she is managing herstoma well but psychologically she is having issueswith her new body image. I arrange to see her theollowing day to chat about liestyle issues, clothingand suggest a suitable person or her to chat with.This can benet patients as it gives them insight into

how others adapt to lie ollowing stoma surgery. Thevoluntary organisations can assist with this as theyoer a patient visitor service. The Beatson reer a

lady who is about to be transerred to the hospice.I ensure she has supplies, reassuring her that thenurses at the hospice are able to assist with care, thatthey will contact me i there are any issues, and I willsee her when I next visit the hospice.

Finally, I visit a man at home who had surgery a ewweeks ago and is recovering well. He is keen to go onholiday and I oer advice including taking adequatesupplies, and supply a travel certicate which states

in various languages that the person is wearing anexternal bag. I arrange to see him again in a couple omonths at the nurse-led clinic at Gartnavel.

Clinical nurse specialists Stoma care


13/24

13

Patient story

Kenny, a colostomist, shares his story

I was rst diagnosed with bowel cancer in the summero 2001, and was operated on to remove the tumourin the December o that year. Unortunately about aweek ater my operation I developed a leak wheremy bowel had been joined. This necessitated anemergency operation in the early hours o Christmasmorning. When I came round rom the operation I wasshocked to nd that I now had a colostomy and wasvery apprehensive about how I would cope with it.

I need not have worried because once the team ostoma nurse specialists became involved I became a

lot less concerned. They really put me at ease, takingme through care o my stoma, changing o my bagand so on, so that by the time I was discharged romhospital, I elt a lot more condent about things.However, any niggling doubts that I still had provedto be groundless as the support I received rom thestoma nurses was excellent, with regular home visitsor the rst ew weeks, advice over the telephone

i I called and seeing me at an outpatient clinic, inecessary.

A couple o years ago I had diculty obtainingthe bags and fanges I used and which I had greatcondence in. The assistance I got rom the stomanurses in obtaining and using suitable alternativeswas invaluable.

I have had urther cause to be grateul to the skilland care o the stoma nurses recently. A ew monthsago the skin around my stoma started to blister, thenpeel o, leaving raw fesh. The stoma nurses didan excellent job o making things bearable or me,and through their persistence they discovered thatmy condition was in act caused by an unusual skincondition or which I am at present being treated. So

I will always have cause to be grateul to the stomanurses and the work they do.



14/24


15


15/24

15

Education

The delivery o education is central to the role o

the nurse specialist in stoma care. Dissemination ospecialist knowledge is o paramount importance toenhancing the patient experience and the educationo others including:

patientsandcarers

wardnurses

communitynurses

generalpractitioners

nursingandmedicalstudents

nursinghomes

alliedhealthcareprofessionals.

Education is undertaken in a variety o settings,

including the local community, hospitals, as well as atcolleges and universities, and incorporates:

one-to-onesessions

theuseofvisualaidsuchasbooklets,videosand DVDs

informalteachingsessions

workshops formallectures

studydays

conferences(local,nationalandinternational)

protectedlearningsessionswithcommunitystaff.



16/24


Patient comments

A selection of comments from patients taken from

the Quality Improvement Scotland Audit 2008

The care given to me by the stoma care nurse was

second to none. She gave me great support during a

very difcult period in my lie.

Stoma nurses are very valuable, oering practical

advice and guidance.

My stoma care nurse has been excellent. She hasbeen a constant source o encouragement and

support and has always been available or advice and

help.

Having had a problem ater discharge with leakage

and appliances, my stoma care nurse has been

excellent with help and advice and I am able to call

her between visits.

Felt I coped much better with a stoma having visits

by stoma nurse in comort o my own home ollowing

surgery. She even helped over anxiety over sexual

aspects.

The confdence and positive attitude I have gained

living with my stoma stems rom the care, advice and

guidance I received rom the stoma nurse specialists.

Research and audit

The implementation o current research, initiating

research, and publishing best practice is integral tothe role o the CNS and is central to ensuring thatpatients receive evidence-based best practice care.

Through the critical analysis o current research andby embracing change, stoma care continues to berecognised as a highly proessional specialty. Sincethe mainstay research published by Barbara Wade, A

stoma is or lie (1989) to present day authors such asJulia Williams, Patricia Black, Sharon Fillingham andTheresa Porrett, stoma care has become associatedwith pioneers o the specialty.

To maintain the delivery o quality services, stomacare departments are audited on a regular basis. Avariety o methods are employed, including patientquestionnaires.

A recent national audit supported by QualityImprovement Scotland (QIS) invited all stomacare departments in Scotland to participate andgenerated a patient response rate o over 70%. Thequestionnaire was designed to capture inormationrelating to the patient experience their stay inhospital beore and ater their operation, caring or

their stoma, and the inormation provided by theCNS and 96% o patients that responded rated theirexperience o care given by the CNS as good or verygood (NHS National Services Scotland, 2008).

17


17/24

17



18/24

p

Consultancy

Colleagues look to nurse specialists or opinions,

inormation, support and solutions with regardto stoma care issues. This consultancy roleensures a consistent and equitable approach tothe management o stoma patients. The service isconsulted by nurses, GPs, and sta rom nursinghomes, community hospitals, as well as NHS24,social services, and any other health care proessionalseeking advice.

I value the expertise o the stoma care service and

the support they oer.

Dr Smith, GP

Consultancy in action

An example of consultancy in action,

provided by Nancy, an Ayrshire-based CNS

I receive a phone call rom a district nurse who wasquite concerned about one o her patients, who wasbleeding rom his stoma. I ask her a ew questionsto help me assess how urgent this problem was, andto establish i the district nurse could resolve this.It becomes apparent I needed to make the journey

to meet the district nurse at the patients home. Onarrival I assess the situation; his stoma bag is hallled with resh blood. I remove his bag to see i Ican identiy the cause o bleeding; there is an area oover-granulated tissue at the side o his colostomywhich had been bleeding and is quite tender totouch. We commence the treatment o silver nitrate,which will be carried out on a weekly basis until

the problem is resolved and arrange or the patientto attend my nurse-led clinic where hell receiveongoing assessment to ensure he is using the mostappropriate products.

19


19/24

9

Management

Due to the ever-changing needs o the patient, daily

schedules requently have to be re-arranged toaccommodate emergencies. A patient may have hada leakage overnight, is distressed and eels unableto come to hospital or ear o urther leakage,necessitating a home visit, or a patient may be aboutto be going into theatre within the hour or emergencysurgery and needs to be given inormation regardinghis surgery and the site marked or the stoma.

To satisy increased service demands, nurse-ledclinics have been established to allow the CNS torespond quickly to patients presenting with problemsand nd solutions which prevent the need or GP orconsultant intervention. At these clinics, patients cantalk about their eelings and gain reassurance aboutreturning to work or going on holiday. Patient reviews

are also undertaken to ensure that appropriateproducts are being prescribed in order to preventproblems rom occurring.

Consultancy in action

An example of consultancy in action,

provided by Isobell, a Lanarkshire-based CNS

I received a reerral rom a GP practice asking ora young gentleman, whod had surgery and anileostomy six months previously, to be reviewed at thenurse-led stoma care clinic. Although coping very wellwith his stoma management, in the last weeks hedbeen having pain and bleeding rom his stoma and

was unable to get a bag to stick.An urgent appointment was arranged or the nurse-led stoma care clinic and the gentleman was reviewedwithin 48 hours. On review, his stoma and peristomalskin were examined; while his stoma was healthy,his peristomal skin was excoriated and numerousulcerated areas noted. During the consultation thegentleman explained that the surrounding area had

become very painul to touch over the last ew weeks.In order to initiate a treatment plan I had to dene thecause o the problem. Was the excoriated skin dueto appliance leakage or management, allergy to theproduct, or another issue?

Due to the act that his stoma was perormed orulcerative colitis, there was ulcerated areas noted and

that he was experiencing severe pain, I decided toreer or a dermatology opinion, he was seen withinve days; biopsies were taken and a skin disorderconrmed and treatment was commenced.



20/24

21


21/24

Summary

There are a reported 100,000 people in the UK with a

stoma (Williams and Ebanks, 2003), and it is thoughtthat about 20% o them will have experiencedclinically signicant psychological problems ollowingtheir stoma-orming surgery (White, 1997). Mostpeople who have a stoma operation have someworries or concerns ater surgery. The practical andpsychological support given by a CNS in stomacare both in hospital and at home contributes

signicantly to an individual making a successuladjustment to lie with a stoma. The continuity o caredelivered by a CNS enhances the patients ability tocope, which in turn promotes reduced readmission tohospital and earlier discharge.

Clinical nurse specialists are a necessity, not a luxury,

or the patient aced with stoma surgery.

Anne Demick, National Secretary o the IleostomyAssociation

The CNS in stoma care also contributes in otherways. Signicant savings or the NHS are achievedthrough the undertaking o patient product reviews,involvement in national procurement and budgetingat a local level, and in the reduction o surgical and GPconsultations.

The health service cannot aord to lose specialist

nursing posts. These posts have been created to

improve outcomes and they are still needed....

Sue Thomas, RCN Nurse Adviser (2007)

Patient story

Cheryl shares her story

I think o my stoma as my new body part that savedmy lie. In June 2006 I returned home rom holiday inMexico with my boyriend. A couple o weeks wentpast and I was suering bad stomach cramps andhad to run to the loo quite oten. In August I wasadmitted to Crosshouse Hospital and diagnosedwith ulcerative colitis, an infammatory conditioncausing bloody diarrhoea. For the next ew monthsater this I was given a variety o medication but withlittle improvement. I was losing a lot o weight andelt very weak; I went rom being a healthy 9 stone to7.5 stone. My consultant at Ayr hospital knew that Iwasnt responding to medication and on 18 NovemberI had emergency surgery and was given an ileostomy,which has totally changed my lie. At 19 I thought that

having a stoma would be the end o my lie but I nowactually have a better quality o lie.

Throughout this time I had regular visits rom mystoma nurse specialist who is antastic and I also hadgreat support rom her colleague. They both kept meup to date with new products and really helped me byanswering lots o questions including advice when Iplanned to go on holiday.

In April I opened my own hair salon and I am now backworking ull time. I have so much more condenceand such positive thinking but thats thanks to mystoma nurse specialists who reassured me thingswould only get better and my amily have also givenme great support. Ater all that I had two weeksholiday in Bulgaria in July. I just wonder what my next

challenge will be.Having a stoma has made me respect my ownindividuality and I have learned to live with it in myown way.



22/24

References

Association o Coloproctology o Great Britain and Ireland (2007) Guidelines or the management o colorectalcancer, London: Association o Coloproctology o Great Britain and Ireland.

Dryden H (2003) Body image, in Faithull S and Wells M (editors) Supportive care in radiotherapy, Edinburgh:Churchill Livingstone.

Humphris D (1994) The clinical nurse specialist, issues in practice, London: Macmillan.

NHS Quality Improvement Scotland (2008) Stoma care audit Scotland: February 2008, Edinburgh: NHS QIS.

Scottish Intercollegiate Guideline Network (2003) Management o colorectal cancer, Edinburgh: SIGN.

Rust J (2009) Understanding the complexities o the clinical nurse specialist: A ocus on stoma siting,Gastrointestinal Nursing, 7 (4), May, pp.18-25.

Thomas S (2007) Spotlight on nurse specialists, RCN magazine, Spring 2007, page 8.

Wade B (1989) A stoma is or lie, London: Scutari.

Waller M (2008) Paediatric stoma care nursing in the UK and Ireland, British Journal o Nursing 17(17):S25-S29

White C (1997) Living with a stoma, London: Sheldon.Williams J, Ebanks A (2003) Types o stoma and associated surgical procedures, Elcoat Ced Stoma CareNursing, Hollister, London.

Williams J (2008) Flatus, odour and the ostomist coping strategies and interventions, British Journal o Nursing17(2) S10-S14.

Further readingBlack P (2000) Holistic Stoma Care, Baillire Tindall: London.Fillingham S and Douglas J (2004) Urological Nursing, Elsevier Ltd: London.

Porrett T and Daniels N (1999) Essential coloproctology or nurses, Whurr: London.

Porrett T and McGrath A (2005) Stoma Care, Blackwell Publishing: London.

Williams J (2002) The Essentials o Pouch Care Nursing, Whurr: London.

23


23/24


24/24

The RCN represents nurses and

nursing, promotes excellence in

practice and shapes health policies.

Published by the

Royal College o Nursing

20 Cavendish Square

LondonW1G 0RN

020 7409 3333

October 2009

Publication code 003 520

ISBN 978-1-906633-14-1

This publication is supported by aneducational grant rom ConvaTecLimited to promote education andbest practice. The views expressed

in the publication are independento ConvaTec.

T

TM

0345 772 6100

Documents

Clinical Nurse Specialists Stoma Care