When marking a patient for a stoma, it is important to consider the practice based on evidence acquired by the wound, ostomy and continence (WOC) nurse during training and experience. Stoma siting procedures are based on evidence-based practices:

• A transparent film dressing, marker, and stoma location disks should be gathered prior to marking the patient.
• The procedure should be explained to the patient in layman’s terms, and privacy should be provided.
• The abdomen should be assessed for markings or contours, and the rectus muscle should be identified; asking the patient to lift their head up, cough, or do a modified sit-up can help with identifying the muscle.¹

Stoma siting within the rectus muscle can help to avoid a peristomal hernia and ectopic placement. Ensuring that the new stoma site is visible to the patient (they should be able to point to it - do not just ask), away from the midline incision if possible (to assist with pouching), and that any individual needs or concerns are addressed, should lend to a good location.¹ If more than one stoma site is selected, they should be numbered in order of choice (ex. #1 is the first choice). This information should be marked on the patient directly, as well as documented in the medical record. Stoma marking is also dependent on the policy of facility, and that particular policy should be followed.

Importance of Preoperative Ostomy Education

After stoma marking is complete, preoperative education should be completed. The topics covered should vary by individual patient situation. For example, if the patient is not a definite stoma (or appears overwhelmed), education should be kept to the basics. If the patient is very eager to learn—or a definite stoma—education should be slightly more extensive, encompassing all topics, even if topics are just briefly mentioned. In the immediate postoperative period, ostomy teaching is not always successful, as one might expect. The patient is experiencing pain (and many other emotions), and changes with their body immediately postoperative, and they are likely groggy from medications given in surgery. Therefore, based on each situation, postoperative ostomy education could probably be initiated on postoperative day (POD) number one. Postoperative ostomy education should include fundamental concepts of ostomy care, emptying the pouch, changing the pouch, troubleshooting (leaks), diet, lifestyle, travel, bathing, and occupation or lifestyle specific education (ex. swimming, hot tubs, belts worn for work, etc.).

Postoperative ostomy education should also include a basic overview of the type of surgery the patient had, the outcome, and answering any questions. Support information, such as in person or virtual (online) support groups, should be suggested during the postoperative education session. It is important to note that the patient needs to be able to empty the pouch prior to being discharged home safely. Information presented should be taught using the “teach-back” method to ensure understanding, comprehension, and ability to complete the task independently (especially if the person lives alone).

Preoperative and Postoperative Ostomy

It is clear that preoperative and postoperative ostomy education truly promotes positive outcomes for new ostomy patients. Many recent qualitative studies indicate that individuals with ostomies do better overall with the support of a WOC nurse and health care team. Werth, et al interviewed a group of new ostomy patients about their teaching and overall hospital experience with ostomy education. This study revealed that these individuals felt teaching related to ostomy self-care was the most beneficial, whereas information related to what support groups were available was least helpful. This brings us to the conclusion that, based on their study, the most important areas for patient teaching post-ostomy creation are basic ostomy care and management, and returning to normal function with essential activities of daily living (ADLs), such as bathing, showering, driving, shopping, being out in the community, etc.²

It is important to note that these findings are consistent with the WOCN Society guidelines and recommendations for preoperative and postoperative ostomy care.² It is critical for new (and experienced) WOC nurses to understand the impact of appropriate stoma siting in the preoperative period, and the effects of sound postoperative ostomy education. Stoma marking has an immediate and continued impact on a person’s quality of life, along with the quality of preoperative and postoperative education the new ostomy patient receives. WOC nurses have the ability to truly provide a positive and lifelong impact on the quality of life for an individual with an ostomy. Stoma siting and pre/postoperative education are not a benefit, but an entitlement to every patient with an ostomy.

References

1. Mahoney MF. Preoperative preparation of patients undergoing a fecal or urinary diversion. In Carmel JE, Colwell JC, Goldberg M, eds. Wound, ostomy and continence nurses society: ostomy management.. Philadelphia, PA: Wolters Kluwer; 2015: 99-112.

2. Werth SL, Schutte DL, Stommel M. Bridging the gap: perceived educational needs in the inpatient to home care setting for the person with a new ostomy. J Wound Ostomy Continence Nurs. 2014 Nov-Dec;41(6):566-72. doi: 10.1097/WON.0000000000000081.

About the Author

Holly is a board certified gerontological nurse and advanced practice wound, ostomy, and continence nurse coordinator at The Department of Veterans Affairs Medical Center in Cleveland, Ohio. She has a passion for education, teaching, and our veterans. Holly has been practicing in WOC nursing for approximately six years. She has much experience with the long-term care population and chronic wounds as well as pressure injuries, diabetic ulcers, venous and arterial wounds, surgical wounds, radiation dermatitis, and wounds requiring advanced wound therapy for healing. Holly enjoys teaching new nurses about wound care and, most importantly, pressure injury prevention. She enjoys working with each patient to come up with an individualized plan of care based on their needs and overall medical situation. She values the importance of taking an interprofessional approach with wound care and prevention overall, and involves each member of the health care team as much as possible. She also values the significance of the support of leadership within her facility and the overall impact of great teamwork for positive outcomes.