RN.ET Ostomy Care And Management Clinical Best Practice Guidelines ET.Nurse Education 20-21 21 Nov. 2009 Pratin Chaisri
Purpose and Scope Best Practice Guidelines are systematically developed statements to assist practitioners and clients decisions about appropriate health care(field&lohr Field&Lohr,, 1990)
Summary of Recommendations
Interpretation of Evidence Ia Ib Evidence obtained from meta-analysis analysis or systematic review of randomized controlled trials. Evidence obtained from at least one randomized controlled trial. IIa Evidence obtained from at least one well- designed controlled study without randomization.
Interpretation of Evidence IIb III IV Evidence obtained from at least one other type of well-designed quasi- experimental study, without randomization. Evidence obtained from well-designed, non- experimental descriptive studies, such as comparative studies, correlation studies and case studies. Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.
Core Recommendations recommendation 1 Develop a therapeutic relationship with the client and family. 2 Perform a comprehensive assessment of the client/family that includes: a) history and physical;b) ) psychosocial (coping and adaptation, altered body image, impaired quality of life, sexuality and sexual concerns); and c) cultural, spiritual and religious norms. LOE III III
Core Recommendations recommendation 3 Consult with interdisciplinary team members for assessment and intervention as needed for all clients requiring, or who already have, an ostomy. 4 Design a mutually acceptable plan of care between the client/family and all health-care providers, which optimizes health and self-efficacy efficacy in ostomy management. LOE IV III
Practice Recommendations: Pre-Operative Phase recommendation 5 Pre-operative education should be provided to all clients and families requiring ostomy surgery. LOE Ib 6 Stoma site marking should be performed on all clients undergoing ostomy surgery. IIa
Practice Recommendations: Pre-Operative Phase recommendation 7 Explore the potential impact of ostomy surgery on intimacy and sexual functioning with the client/partner. LOE Ia 8 Progressive Muscle Relaxation Therapy (PMRT) should be offered to clients undergoing ostomy surgery as part of routine care. Ib
Practice Recommendations: Post-Operative Phase recommendation 9 Assess the stoma immediately post- operatively and the stoma/peristomal skin condition with each appliance change using a validated classification tool to monitor for complications. 10 Identify risk factors that influence stomal and peristomal complications. 11 Review the client s s medication profile to ensure that maximum absorption and effectiveness will be achieved in relation to the type of ostomy. LOE IV III IV
Practice Recommendations: Post-Operative Phase recommendation 12 Avoid insertion of a glycerin suppository into a colostomy in order to aid evacuation of effluent. 13 Counseling by a Registered Dietician should be performed for clients with an ostomy who are at risk for, or who develop, nutritional complications. LOE Ib IIa
Practice Recommendations: Post-Operative Phase recommendation 14 Prepare the client and family by teaching the minimum skill set specific to their needs prior to discharge from hospital. 15 Discharge the client and family with home care support. LOE IV Ib
Practice Recommendations: Post-Operative Phase recommendation 16 Ensure that the ostomy plan of care is individualized to meet the needs of the client and family. 17 Assessment and follow-up by an Enterostomal Therapy Nurse (ETN) are recommended for the client and family after ostomy surgery to decrease psychological distress, promote optimal quality of life and prevent complications. LOE IV IIb
Practice Recommendations: Post-Operative Phase recommendation 18 Educate client and family members to recognize complications affecting the stoma and peristomal skin. LOE IV 19 Colostomy irrigation may be implemented as a safe and effective method for the management of descending or sigmoid colostomies for select adult clients. III
Education Recommendations recommendation 20 Ostomy education for all levels of health-care providers should be a systematic, client-centred centred process, provided in both academic and workplace venues. 21 Consult ETNs in the development of ostomy educational programs that target appropriate health-care providers, clients, family members and caregivers. LOE IV IV
Organization & Policy Recommendations recommendation 22 Organizations should utilize a credentialed ETN for policy development and program management. 23 All clients with ostomies,, and their families, should have access to comprehensive education. LOE IV IV
Organization & Policy Recommendations recommendation 24 A mechanism must be in place for the transfer of information between care settings to facilitate continued education and clinical support of the client. 25 Practice settings must have access to an interdisciplinary team of knowledgeable and skilled health professionals to address quality care in ostomy management. LOE IV IV
Organization & Policy Recommendations recommendation 26 Nursing best practice guidelines can be successfully implemented only where there are IV adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes: 1. An assessment of organizational readiness and barriers to implementation, taking into account local circumstances. LOE IV
Organization & Policy Recommendations recommendation 26 2. Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. 3. Ongoing opportunities for discussion and education to reinforce the importance of best practices. LOE IV
Organization & Policy Recommendations recommendation 26 4. Dedication of a qualified individual to provide the support needed for the education and implementation process. 5. Ongoing opportunities for discussion and education to reinforce the importance of best practices. 6. Opportunities for reflection on personal and organizational experience in implementing guidelines. LOE IV
1. 2. Ostomy Patient Care Standards Outcome Standards 1. Patient demonstrates manageable level of anxiety as evidenced by verbal and non-verbal 2. Patient demonstrates positive self- concept as evidenced by verbal and nonverbal indicators of self-esteem esteem (ability to cope, plans to resume lifestyle and relationships, continued self-care activities, grooming).
3. Outcome Standards 3. Patient/family demonstrate adaptive grieving as indicated by ability to share feelings, ability to share emotions in a healthy manner, ability to participate in activities of daily living and decision- making.
4. Outcome Standards 4. Patient/family verbalize understanding of disease process, planned medical/surgical procedure/treatment, alterations in physical appearance and options for management as a result of medical/surgical intervention.
5. 6. Outcome Standards 5. Patient/family describe anticipated effects of medical/surgical intervention on lifestyle including occupational, school, social and sexual aspects. 6. Patient has optimal stoma site placement to promote self-care and rehabilitation.
1. Post-operatively operatively and Ongoing 1. Patient attains/maintains adequate nutritional status as indicated by laboratory values reflecting protein stores and other clinical indicators of nutritional status (weight, general appearance, presence/absence of edema, decreased muscle mass, appetite, nutrient intake). More applicable to an ileostomy
2. Post-operatively operatively and Ongoing 2. Patient maintains adequate fluid and electrolyte balance as evidenced by fluid intake, urinary output, vital signs, electrolytes, hemoglobin, haematocrit,, and absence of signs and symptoms of fluid/electrolyte imbalances. More applicable to an ileostomy.
Post-operatively operatively and Ongoing 3. Patient and/or family describe daily Ileostomy/Colostomy care and options for management. 4. Patient and/or family demonstrate how to properly empty and change the ostomy pouching system.
Post-operatively operatively and Ongoing 5. Patient attains/maintains intact peristomal skin and incisional tissue integrity. 6. Patient and/or family demonstrate understanding of appropriate peristomal skin care for prevention/management of breakdown.
7. Post-operatively operatively and Ongoing 7. Patient and/or family demonstrate an understanding of potential complications following Ileostomy/Colostomy surgery and measures to take if complications should occur. Potential complications include mechanical/food-related blockages, high Ileostomy outputs.
Post-operatively operatively and Ongoing 8. Patient verbalizes ability to resume, maintain or initiate a satisfactory sexual relationship. 9. Patient/family will resume role-related related responsibilities and relationships to extent patient and family have set goals for.
Post-operatively operatively and Ongoing 10. Patient and/or family identify/assess the resources needed for effective management of Ileostomy/Colostomy in home setting.
Process Standards Members of the multidisciplinary team become involved with the patient/family either through direct referral from the primary nurse, physician, or other team member; discussion at "bullet rounds"; patient care conferences; pre-admission questionnaire that would identify "at risk" patients or at the pre-admission visit.
Process Standards 1. In collaboration with the team, the nurse assesses the patient/family's level of anxiety and plans interventions aimed at reducing anxiety, as appropriate. 2. In collaboration with the team, the nurse assesses the patient/family's perception of the surgery/medical intervention in relation to effect on self-concept and plans interventions aimed at attaining/maintaining a positive self-concept.
Process Standards 3. In collaboration with the team, the nurse assesses the patient/family's grieving response and plans interventions to facilitate the normal grieving process. 4. In collaboration with the team, the nurses assesses the patient/family's understanding of the diagnosis, prognosis, planned medical/surgical intervention and initiates /reinforces patient/family education based on readiness and ability to learn.
5. Process Standards 5. In collaboration with the team, the nurse assesses the potential effect of surgery (Ileostomy( Ileostomy/Colostomy) on the patient s s lifestyle and initiates/reinforces patient/family education as well as interventions aimed at providing support.
Process Standards 6. In collaboration with the team, the nurse ensures that stoma siting according to pre- established criteria is completed pre-operatively. 7. In collaboration with the team, the nurse assesses the patient s s nutritional status and plans interventions aimed at maintaining/restoring nutritional status. 8. In collaboration with the team, the nurse assesses the patient s s fluid and electrolyte balance and plans interventions aimed at maintaining/restoring balance
Further Reading Clinical Best Practice Guidelines: Ostomy Care and Management ; Registered Nurses Association of Ontario (RNAO), August 2009. Ostomy Patient Care Standards : Mount Sinai Hospital Internet; http:// WWW.mountsinai.on.ca Lippincott s s Nursing Center.com: http://www.nursingcenter.com