Structure

Four layers of tissue form the walls of the large intestine:

There are several modifications to the muscle layer. Two folds of the circular muscle layer form the ileocaecal valve, which controls the passage of material from the ileum to the caecum (first part of the large intestine). The circular muscle layer also forms the anal sphincters: the internal (involuntary, smooth muscle) and the external (voluntary, skeletal muscle). The longitudinal muscle layer in the colon consists of three bands called taeniae coli (Fig. 21.2). As the bands are shorter than the colon they produce a puckered or sacculated appearance. The sacculations are known as haustrations. The rectum and anal canal are completely surrounded by longitudinal muscle fibres, so there are no haustrations.

Fig. 21.2 Rectum and anus

(adapted with permission from Waugh & Grant 2001)

The submucosal layer contains lymphoid tissue that provides some defence from invading microbes. The mucosal lining of the colon and upper part of the rectum has a large number of mucus-secreting cells.

The mucosa in the upper part of the anal canal is arranged in vertical folds, known as the anal or vertical columns (see Fig. 21.2). Each column contains a terminal branch of the superior rectal vein and artery. The anus is lined with stratified squamous epithelium, which is continuous with the rectal mucosa above and merges with the perianal skin outside the external sphincter.

The large intestine is about 1.5 metres in length. It comprises the caecum, colon (ascending, transverse, descending and sigmoid), rectum and anal canal (see Fig. 21.1).

The caecum is the dilated first part of the large intestine. It has a worm-like appendix – the vermiform appendix – that extends from it. The appendix has a blind end and contains lymphoid tissue. Just above the lower end of the caecum there is a T-junction where the ileocaecal valve opens into it.

The colon is divided into the ascending, transverse, and descending colon in relation to its anatomical position (see Fig. 21.1). The ascending colon runs from the caecum, up the right side of the abdominal cavity. When it reaches just below the liver, it makes a 90° turn to form the hepatic (right colic) flexure. It then becomes the transverse colon where it crosses the body below the stomach until it reaches the spleen. It turns again at the splenic (left colic) flexure and becomes the descending colon as it passes down the left side of the abdominal cavity, moving towards the midline. As the descending colon enters the pelvis it becomes the sigmoid colon and then the rectum. The rectum is a slightly dilated section of colon, about 3 cm in length in infants, growing to 13 cm in adults, terminating at the anal canal.

The anal canal leads from the rectum to the exterior. It has two muscular sphincters, one internal, one external, which are involved in the process of defecation (see Fig. 21.2 and below).

Functions

Functions of the large intestine, rectum and anal canal include:

The waste material that reaches the large intestine normally remains there for approximately 12–24 hours prior to expulsion from the body as faeces. There is some digestion of the waste products by the bacteria that colonize the large intestine, but no further food breakdown occurs. The bacteria include Escherichia coli, Enterobacter aerogenes, Streptococcus faecalis and Clostridium perfringens. Many colonic bacteria have the capability to become pathogens should they be transferred to another part of the body (see Ch. 15). The bacteria metabolize remaining carbohydrates and amino acids, releasing gases, e.g. hydrogen, which contribute to faecal odour. Normally the build-up of gas is expelled from the anus as flatus. People vary but some foods such as onions tend to produce excessive flatus. Flatus has an offensive odour due to bacterial decomposition of food residues in the colon. In Western society the passing of flatus is considered as a natural bodily function, but offensive and unacceptable in public.

There is some microbial vitamin production, mostly vitamins K and B group. Absorption in the large intestine is mostly of these vitamins, some electrolytes and water.

The remaining faecal mass is propelled towards the rectum by mass movements, long, slow and powerful contractile waves that move over large areas of the colon three or four times daily. These movements usually occur during or just after eating, indicating that it is the presence of food in the stomach and small intestine that activates the gastrocolic and duodenocolic reflexes. This may then lead to defecation.

Assessing normal bowel habit – patterns of defecation and characteristics of faeces

Normal bowel habit varies from person to person and changes during the lifespan. However, in a study of adults admitted to hospital, the usual bowel habit prior to admission was five to seven stools weekly (Wright 1974).

The assessment of stool type can be enhanced by the use of a pictorial assessment tool such as the Bristol Stool Form Scale (Fig. 21.3A, p. 604) or the Children’s Bristol Stool Form Scale, which uses child-friendly language to describe stool type (Fig. 21.3B, p. 604). In addition, the nurse should measure fluid stools and record the volume lost on the fluid intake and output chart (see Ch. 19). Table 21.1 (p. 605) outlines the normal characteristics of faeces and defecation and some abnormalities.

Fig. 21.3 A. Bristol Stool Form Scale

(reproduced by kind permission of Dr KW Heaton, Reader in Medicine at the University of Bristol. ©2000 Norgine Ltd). B. Children’s Bristol Stool Form Scale (Concept by Professor DCA Candy and Emma Davey, based on the Bristol Stool Form Scale by Dr KW Heaton, Reader in Medicine at the University of Bristol. ©2005 Norgine Ltd) For further copies of the Bristol Stool Form Scales please freephone Norgine on 0800 269865 or email mss@norgine.com

Nursing history

When assessing and taking a history of a person’s bowel habit the nurse must ask about normal bowel habit and any changes that have occurred. It is important to note when any changes first occurred and for how long they have been present, as unexplained changes may indicate diseases such as cancer. The nursing history typically includes information about the following:

A holistic assessment will also ascertain how culture, beliefs and religious practices influence defecation (see p. 609). Acknowledging this individuality will ensure that the person’s needs are met.

Some people will resist the urge to defecate if this means using a lavatory other than their own and individual bowel assessment must incorporate any psychological and environmental factors affecting bowel habit.

It can be helpful for patients/parents to keep a diary of bowel actions to establish a pattern; this is particularly helpful when bowel-training programmes are in progress. Nurses should record bowel actions in the nursing notes and on the appropriate charts, e.g. a stool record chart (Fig. 21.4, p. 606) and episodes of diarrhoea are measured and recorded on the fluid intake and output chart.

Fig. 21.4 Stool record chart

Common investigations

There are many different investigations used to identify disorders affecting the large bowel and elimination of faeces (Box 21.8, p. 607; see also Ch. 19).

Bedpans and commodes

Some patients will need to use a bedpan or commode (Fig. 21.6, p. 610). Most people will find this embarrassing and nurses must be aware of these worries and take all necessary steps to maintain the person’s privacy and dignity and provide culturally sensitive care.

Fig. 21.6 A. Bedpan. B. Commode

Using a bedpan may lead to worries over spillage in the bed or the escape of offensive sounds or smells in the ward. Bedpans are difficult to balance on, and getting a patient on a bedpan requires the nurse to complete an appropriate risk assessment for moving and handling (see Chs 13, 18), ensuring that neither patient nor nurse safety is compromised. Box 21.16 (p. 610) outlines how the nurse can provide a bedpan or commode safely while maintaining privacy and dignity.

A commode can be used for patients with more mobility. It has the advantage of providing a more normal position for defecation and can be used in the lavatory for greater privacy. The commode can be used beside the bed, if privacy and dignity can be ensured (see Box 21.16). Alternatively, the patient may be transferred from the bed to a wheelchair, taken to the lavatory and there transferred to the commode, which may then be moved over the lavatory. Again a risk assessment is undertaken and safe moving and handling procedures adhered to (see Chs 13, 18). The commode should never be used for transport between the bed and lavatory due to the risk of cross-infection.

Contributing factors and causes of constipation

The dry, hard stools of constipation occur when the colon absorbs too much water. This happens when the muscular contractions of the colon are sluggish, causing the stool to move too slowly through the colon. Lack of fibre in the diet reduces bulk, slowing down motility. Most people will experience an episode of constipation at some time or another such as following childbirth or surgery.

Constipation affects all age groups but it is the very young and older adults who are affected most. People worry more about their bowels as they age, but ageing does not in itself slow down stool movement in the colon (Norton 1996). This is usually due to other factors such as lack of exercise and a reduction in the consumption of fruit, vegetables and bread, increasing the risk of constipation. Fibre intake is positively associated with increased frequency of bowel movement and faecal mass (Bennett & Cerda 1996). The prevalence of constipation may be increasing as modern food processing methods have produced a refined fibre-free diet (Taylor 1997). Other risk factors contributing to the development of constipation may be reduced fluid intake. Older people may drink less in an attempt to control urinary incontinence (see Ch. 20), particularly if mobility is poor and assistance with reaching the lavatory is required.

Box 21.2 (p. 602) outlines the many factors that affect defecation and bowel habit, including those that cause constipation. However, nurses should always be aware of situations when constipation is likely to occur and anticipate the need for interventions, e.g. laxatives when opioid drugs are used for pain relief (see Ch. 23).

Effects of constipation

The effects of constipation are outlined in Box 21.17.

Assessment of constipation

A thorough and complete assessment and history are essential to determine the normal bowel habit for the person (see pp. 603–605) and to identify contributing factors or causes for the condition (see Box 21.2, p. 602). Consti-pation can be a chronic problem for many individuals.

Self-assessment of bowel habit is also helpful and the person or parent can be taught the use of the Bristol Stool Form Scale (see Fig. 21.3, p. 604). The person may be asked to log their dietary and fluid intake and keep a record of daily exercise.

A doctor or a registered nurse who is appropriately trained and competent will perform a physical examination. This will include:

Management of constipation

Most people who experience constipation will not require extensive investigation and can be successfully treated with lifestyle changes that include increasing fluid intake, exercise and fibre content of the diet (Box 21.18, p. 612).

In the short term, laxatives may be prescribed to relieve constipation. They are only used if the person is constipated and the cause is not an undiagnosed condition such as intestinal obstruction. Laxatives (or aperients) are drugs that cause the bowel to empty in a variety of ways. There are four basic types, plus bowel cleansing solutions (Table 21.3):

Table 21.3 Laxatives – oral and rectal

Laxatives can be administered orally, rectally as suppositories or as an enema for severe constipation. Many patients will be able to self-administer enemas or suppositories and parents/carers can also be shown how to administer them to children and others. However, it does require a degree of mobility and manual dexterity. People who self-administer should be directed to the manufacturer’s instructions and advised to contact their practice nurse or general practitioner if problems arise.

Bowel cleansing solutions are used to empty the lower bowel before investigations that include colonoscopy and barium enema X-ray (see Boxes 21.8 and 21.9, p. 607) and before surgery. Laxatives are also prescribed to prevent constipation, e.g. when people are receiving morphine or other opioid drugs to relieve pain.

Readers requiring more information about a specific laxative are directed to the British National Formulary (www.bnf.org.uk).

Enemas

An enema is the introduction of fluid into the rectum or lower bowel for the purpose of producing a bowel movement or instilling medication. The drugs administered rectally include corticosteroids used in inflammatory bowel disease, etc. (see Ch. 22).

The are two types of enema available for the management of constipation: evacuant and retention.

• Evacuant, e.g. phosphate enemas supplied in single-dose packs with a standard or long rectal tube, or sodium citrate micro enema (Fig. 21.7). These are used to evacuate the rectum and lower colon of flatus and faecal matter. The enema solution is retained for a short time only (always follow the manufacturer’s recommendations and local policy) and is then expelled from the bowel along with faeces and flatus

  Page 613 

• Retention, e.g. single-dose arachis oil enema (see Fig. 21.7). Retention enemas are usually retained in the bowel for a longer period of time than an evacuant enema in order to soften and lubricate impacted faeces, making it easier to pass.

Fig. 21.7 Types of enema

(reproduced with permission from Nicol et al 2004).

Fig. 21.8 Left lateral position for administration of enemas and suppositories

Fig. 21.9 Position of suppository – blunt-end foremost

Before administering an enema it is necessary to obtain informed patient/parent consent.

In order to give informed consent the patient must understand what an enema involves. A clear explanation is required so that the patient understands what is required of them, i.e. retention of the enema solution. The patient must understand the benefits and risks of the intervention in relation to symptom relief, and that this will be short term. The nurse should also consider who is best to administer the enema. For example, a nurse of the same gender as the patient may minimize embarrassment and should be offered whenever possible.

There are contraindications to giving an enema. These include:

• Intestinal obstruction

• Paralytic ileus – lack of peristalsis, common after surgery when the bowel has been handled

• Where there is risk of circulatory overload (see Ch. 19)

• Following certain types of gastrointestinal or gynaecological surgery unless written medical consent is given

• Inflammatory bowel disease (IBD).

The enema must be prescribed by an appropriately qualified practitioner and local policy followed regarding checks on medication and patient identity for the administration of medicines (see Ch. 22). Box 21.19 (p. 614) outlines how the nurse can administer an enema safely and effectively while maintaining privacy and dignity.

Box 21.19 NURSING SKILLS

Enema administration – adults

Equipment

• Incontinence pads to protect bed/trolley

• Disposable gloves and apron

• Disposable wipes and tissues

• Prescribed enema/prescription chart

• Jug of water at required temperature, bath thermometer

• Lubricating gel

• Commode or bedpan and tissue, or access to a lavatory.

Preparation

• Explain the procedure to ensure informed consent

• Check that patient does not have a peanut/groundnut allergy before giving an arachis oil enema

• Ensure privacy by using a treatment room or pull curtains around the bed. Ask other staff to avoid interruptions

• Warm the enema in a jug of warm water until the required temperature is reached. Follow the manufacturer’s recommendations for single, pre-prepared products. Mallet and Doherty (2000) recommend that the enema be warmed to body temperature, or just above. Oil retention enemas are warmed to 37.8°C

• Assist the patient into the left lateral position, with knees flexed (Fig. 21.8). This allows the nozzle or tubing of the enema to follow the natural anatomy of the colon and gravity will also help flow and/or retention of any solution used (Mallet & Doherty 2000)

• Place an incontinence pad/sheets under the patient’s hips and buttocks to protect the bedding and relieve potential distress if fluid is expelled from the anus

• Cover the lower body with a blanket to maintain dignity

• Put on a protective apron, wash hands and put on non-sterile gloves (see Ch. 15).

Procedure

• Lubricate the enema nozzle to minimize anal/rectal trauma

• Separate the patient’s buttocks and observe for soreness or other abnormalities

• Introduce the nozzle into the anal canal, which is approximately 3.8 cm in length in adults, and then advance to approximately 10 cm to ensure the tip reaches the rectum. This is normally the full length of the nozzle for pre-prepared enemas

• To administer an evacuant enema, roll the packaging slowly from bottom to top to prevent backflow of the solution into the packet

• Remove the nozzle slowly while still keeping the bag rolled, and encourage the patient to hold onto the solution for as long as possible; however, the effect can be rapid and the patient should not be left without easy access to a nurse call bell

• A retention enema should also be introduced slowly. Again the patient is encouraged to hold onto the solution for as long as prescribed. If possible, this may be aided by raising the foot of the bed against gravity

• Wipe the patient’s perianal/perineal area and leave them clean and dry. Cover the patient

• Ensure access to a nurse call bell, a bedpan, a commode or lavatory. When called, give any assistance required (see Box 21.16, p. 610)

• Take the commode or covered bedpan with protective sheet to the sluice

• Observe the colour, amount and consistency of the stool passed (see p. 605)

• Collect faecal specimen if required (see Box 21.22, p. 617)

• Wash/sterilize/dispose of the bedpan, or clean the commode according to local policy (see Ch. 15)

• Remove and dispose of apron and gloves and wash hands (see Ch. 15)

• Return to the patient to offer facilities for personal hygiene and handwashing: wet and dry wipes, or a bowl, jug of water and hand towels (see Ch. 15). Respect cultural preferences

• Ensure that the patient is comfortable and has everything they need, e.g. call bell, drink, within reach

• Make sure the immediate environment is tidy, use air-freshener as necessary and open the curtains

• Document the type of enema given, the resultant bowel action and any specimens collected in patient records and report any abnormalities

• Continue to monitor bowel function, along with reassessment and evaluation of the patient’s presenting symptoms.

Contributing factors and causes of diarrhoea

Chronic diarrhoea may be associated with underlying pathology such as IBD (see Table 21.2, p. 606) or mal-absorption due to lactose intolerance. The causes of acute diarrhoea include:

Box 21.2 (p. 602) outlines other factors that cause diarrhoea. Nurses should always be aware of situations when diarrhoea may occur and anticipate the need for interventions that include ensuring the person’s bed/room is close to the lavatory.

Effects of diarrhoea

The effects of diarrhoea are outlined in Box 21.21 (p. 616).

Assessment of diarrhoea

A thorough and complete assessment and history are essential to determine the normal bowel habit for the person (see pp. 603–605) and to identify any contributing factors or causes for the diarrhoea (see Box 21.2, p. 602).

Episodes of diarrhoea are recorded on a stool chart (see Fig. 21.4, p. 606). Frequent, loose watery stools should be measured and recorded on the fluid intake/output chart in order to assess fluid loss. Self-assessment of bowel habit using, for example, the Bristol Stool Form Scale (see Fig. 21.3, p. 604) can be helpful. The person may also be asked to record their dietary intake.

A specimen of faeces may be collected for microbiological examination (Box 21.22, p. 617).

Management of diarrhoea

Management depends on whether the diarrhoea is acute or chronic. It is important to prevent dehydration and adults and children are advised to take frequent sips of water. Oral dehydration salts can be purchased over-the-counter following advice from the pharmacist (see Ch. 19).

The advice about eating has changed and both adults and children are encouraged to eat high carbohydrate foods, e.g. rice, pasta, etc. if they feel well enough (NHS Direct 2005). Where people do not feel like eating they should continue to drink and try to eat when they feel able.

Babies with diarrhoea should be fed as normal if they will breastfeed or take formula milk. The formula feed should be made up at the usual strength. If oral rehydration preparations are used, breast or formula milk should continue to be offered between oral rehydration fluids (British National Formulary 2005).

Adults may use antidiarrhoeal drugs, e.g. loperamide. However, anyone with a high temperature, or blood or mucus in their stool, should first seek medical advice. Parents and carers should not give over-the-counter antidiarrhoeal drugs to children. If symptoms persist, or signs of dehydration are present, medical advice must be sought.

Other nursing interventions for a person with diarrhoea include the following:

Contributing factors and causes of faecal incontinence

The causes of faecal incontinence include:

Factors that contribute to faecal incontinence include dementia, lack of facilities or poor access, immobility and poor manual dexterity.

Box 21.2 (p. 602) outlines factors that affect bowel habit, many of which can lead to loss of continence, e.g. faecal impaction with overflow (spurious) diarrhoea. Nurses should always be aware of situations when continence may be lost and anticipate the need for interventions that include the use of laxatives to minimize constipation when patients are prescribed opioids.

Effects of faecal incontinence

The effects of faecal incontinence are outlined in Box 21.25.

Access to a lavatory or other facility is a major concern for all patients who experience urgency to defecate. This is a common problem for people with IBD who also have bowel actions that are explosive, noisy and malodorous (Box 21.26).

Assessment of faecal incontinence

A full patient history and physical assessment are essential to determine the normal bowel habit for the person (see pp. 603–605), and to identify any contributing factors or causes for faecal incontinence (see Box 21.2, p. 602). Physical factors such as mobility and manual dexterity and access to appropriate facilities for defecation must form part of any assessment, along with assessment of factors such as cognition and motivation.

Episodes of incontinence can be recorded on a stool chart (see Fig. 21.4, p. 606) and self-assessment of bowel habit using, for example, the Bristol Stool Form Scale (see Fig. 21.3, p. 604) can be helpful. The person, parent or carer may also be asked to record food and fluid intake and regular exercise pattern.

Managing faecal incontinence

The management of faecal incontinence will depend upon the cause. It is often secondary to constipation and may be resolved through the following:

A toileting programme that closely follows the person’s previous normal bowel habit, such as sitting on the lavatory after breakfast, can be very helpful. For patients requiring assistance to the lavatory, an immediate response from the nurse to the patient’s request is essential before the gastrocolic reflex subsides.

The specialist continence nurse/adviser can provide information and education about prevention of faecal incontinence and measures to regain continence (see Further reading, e.g. Wells 2003).

When patients have impairment of both sensation and sphincter control, as in conditions such as multiple sclerosis, the bowel is usually emptied by routine administration of enemas or suppositories (see pp. 214, 215). The National Institute for Health and Clinical Excellence provide guidance for the management of bowel problems for people with chronic conditions which recommend that the patient be assessed and considered for the routine use of enemas or suppositories (NICE 2003).

Antidiarrhoeal drugs such as loperamide may be used to produce a more formed stool if the faecal incontinence is due to a very liquid stool.

More advanced methods such as biofeedback may be used by specialist nurses and physiotherapists to retrain the anal sphincter muscles that control release of bowel movement. Other methods for managing faecal incontinence may be more radical and involve surgery; these interventions will be specific to the cause, i.e. rectal prolapse.

Continence may not be achievable and nurses will need to plan care that minimizes the effects while continuing to promote continence. The care will include:

Encopresis

There is sometimes confusion caused in diagnosis of encopresis and faecal soiling with other childhood problems. For example, fear associated with using the lavatory may lead to a child soiling their clothes. Children who are isolated and lonely may smear faeces; however, this is different from encopresis, as they have control of their bowel and their behaviour is a symptom of an emotional disorder (Heins & Ritchie 1985).

In most cases of encopresis, prolonged constipation and faecal impaction is the most likely cause. Stretch receptors in the rectum are continually stimulated because the rectum is full of faeces and this leads to the prohibition of signals and loss of the normal response of muscle contraction. It can take 2–6 months for an overstretched rectum to return to normal functioning (Heins & Ritchie 1985).

For a school-age child, social acceptance is important; a feeling of belonging and inclusion among peers will aid development of self-esteem and confidence (Gross 2001). A child with encopresis is likely to experience difficulties (Box 21.27). The child may be unable to wash/change in privacy after faecal soiling and this may lead to ‘being smelly’ and a focus of fun for other children. The child may avoid activities such as games where there is a need to undress in public. Opportunities to go on school trips and sleepovers may be rejected to avoid embarrassing situations. The response from parents/carers is important, as family support is vital; reprisal and rejection from constant criticism and telling off will only lead to further isolation and lowering of self-esteem (Gross 2001).

The MDT will usually be involved in planning strategies and supporting the child and family in resolving the problem. The composition of the team will depend on the cause of the child’s encopresis. They may include the specialist continence nurse, GP, psychologist, school nurse, community nurse and dietitian.

Strategies used to resolve encopresis will include dealing with constipation and education (see pp. 611–612) about diet and exercise to avoid recurrence once the current episode has been relieved.

The bowel has to regain the ability to respond to stretch receptor signals, and also to contract and relax to expel faeces from the bowel. Recording the times that faecal soiling occurs will give some indication of when the child should be encouraged to visit the lavatory. Visiting the lavatory each morning will reduce the amount of faeces left in the bowel and hence the risk of soiling later in the day. A breakfast comprising a high-fibre cereal such as porridge will help but a laxative may be necessary.

Choosing high-fibre options such as fruit and vegetables from school dinner menus or healthy sandwiches made with granary bread with salad and a fruit snack, plus sufficient water for the day, is essential. Again, visiting the lavatory after meals (usually 20 minutes) when the bowel muscles begin to respond to the feeling of fullness is important. Informing teachers of the need to access lavatory facilities, even though this may disrupt lessons, is important, as is access to somewhere private to change for physical education lessons.

Specific preoperative care for patients having a stoma

Preparation for stoma formation will depend on the reason for surgery, and whether it is planned or undertaken as an emergency. Readers are directed to Chapter 24 for details of general preoperative care.

Physical and psychological preparation should include:

Specific postoperative care for a patient having a stoma

Postoperative care following stoma formation is also influenced by the reason for surgery, and whether it was planned or undertaken as an emergency. Readers are directed to Chapter 24 for details of general post-operative care.

Specific postoperative care should include:

Appliances and skin care

It is usually 48 hours postoperatively that the drainable appliance put on in theatre is changed for the first time (Black 2000). It is usual practice to use a clear plastic pouch when in hospital as this allows the nurses to observe the stoma and any output directly. Patients are initially very distressed by the odour produced when the pouch is emptied or changed, and should be reassured that this will decrease as diet is reintroduced (Black 2000). Pouches that are opaque and have flatus filters and contain charcoal to reduce odour can be introduced later should they be required (see p. 622).

Appliances may be either one- or two-piece, with a flange, sealed or drainable (Fig. 21.11). A two-piece appliance allows the flange to remain in contact with the skin and the pouch can be removed and changed without disturbing the flange. The flange is usually changed every 2–3 days; however, it may be left for longer when skin is sore to avoid further irritation (manufacturer’s guidelines must always be followed). Sealed pouches are often used with a colostomy, and although the contents can be flushed down the lavatory, the bags must be placed in a plastic disposal bag and disposed of with normal household waste.

Fig. 21.11 Selection of stoma pouches/bags – front and back views: A. Drainable pouch/bag. B. Sealed pouch/bag. C. Opaque pouch/bag (drainable).

Fig. 21.12 Stoma measurement tool

Fig. 21.13 Changing a stoma pouch/bag: A. Fitting the flange. B. Stoma pouch/bag in place

(reproduced with permission from Nicol et al 2004)

Patients with an ileostomy generally use a drainable pouch. Patients are encouraged to protect the skin around the stoma with a barrier cream.

Skin must be kept in optimum condition to tolerate the stoma appliance. Karaya, a natural absorbent rubber, revolutionized stoma care in the 1950s. However, some patients developed allergies and difficulties with adherence (Black 2000). It is still used by some patients who have had a stoma for many years.

In 1972 Stomahesive® was introduced. It is a flat wafer that is resistant to temperature, perspiration and the gastrointestinal fluids which come into direct contact with it. Stomahesive can be tolerated by inflamed and weepy skin and can be left in place for up to 15 days without requiring change.

When appliances are changed the skin should be cleansed and dried. Protective wafers should be used to fix appliances to the skin. If skin is prone to inflammation the longer the wafer can remain in situ the better, meaning a two-piece appliance would be worn.

The therapeutic relationship between the patient and the healthcare team is important in assisting the patient in accepting the stoma. By seeing the nurses at ease when providing early stoma care, patients/parents and carers are more likely to accept the changes to their physical appearance. Box 21.30 outlines the procedure for changing a stoma pouch.

Continuing stoma care – advice and support for patients

Various designs and colours of pouches are available, including some designed specifically for children. Pouches and appliances are designed to lie flat, be odour-free, rustle-free and to be unnoticeable under clothing. Some pouches have an inner lining that can be flushed with the contents down the lavatory, and soft cloth covers are available for some pouches. Appliances can be left in place or removed during bathing/showering. Once the patient has found a suitable appliance, the stoma care nurse will advise them about obtaining supplies after discharge.

Prior to discharge all stoma patients should be given contact numbers/email address for the stoma care nurse. When patients are discharged from hospital they are supplied with sufficient appliances for at least the first week with extra to cover any public holidays. The district nurse or GP will provide prescriptions for appliances. Continuation of supplies may be direct from the manufacturer or from the local pharmacy.

Following discharge, the GP, district nurse and the stoma care nurse who works between the hospital and community assist the patient/parent to prevent or overcome any problems that arise. Other members of the MDT such as the dietitian may also provide specialist advice. In the case of children the specialist community public health nurse (health visitor) and school nurses will also be involved in their ongoing care.

Clothing which has some stretch and give provides most comfort by avoiding the restrictions of waistbands and belts.

Most patients will quickly discover any food or drink that upsets the function of their stoma, e.g. changes in stool consistency, odour, blockage or excess flatus. However, they should be given advice regarding eating a balanced diet (see Ch. 19) and informed about food and drink that are known to cause problems. For example, beer and onions can cause flatus, and eggs and onions are associated with odour. Many patients find that a bulkier stool is more manageable and will want to increase their intake of fibre with, for example, bananas, boiled rice, pasta, etc.

Support groups are very useful sources of information and support (see ‘Useful websites’, p. 625). These groups provide information about travelling and holidays, special appliances for sports and swimming for adults and children, etc. Patients whose stomas function at regular times can use a special cap while swimming instead of a pouch.