Ostomy care and management


Guideline Summary: Ostomy care and management. [Registered Nurses' Association of Ontario]

National Guideline Clearinghouse (NGC). Guideline Summary: Ostomy care and management. [Registered Nurses' Association of Ontario] In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): cited 1984 Apr (revised 2009 Aug 01). Available: http://www.guideline.gov.

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Guideline Title
Ostomy care and management.
Bibliographic Source(s)
Registered Nurses' Association of Ontario (RNAO). Ostomy care and management. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2009 Aug. 115 p. [101 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Ostomies (temporary or permanent), including colostomy, ileostomy, and urostomy, are performed for a number of etiologies such as, but not limited to:

  • Colorectal cancer
  • Inflammatory bowel disease
  • Bladder cancer
  • Diverticulitis
  • Necrotizing enterocolitis
  • Congenital anomalies
  • Hirschsprung's disease
  • Other cancers
  • Other conditions such as obstruction, perforation, and trauma
Guideline Category
Counseling
Evaluation
Management
Prevention
Risk Assessment
Clinical Specialty
Colon and Rectal Surgery
Critical Care
Emergency Medicine
Family Practice
Gastroenterology
Geriatrics
Internal Medicine
Nursing
Oncology
Pediatrics
Preventive Medicine
Surgery
Urology
Intended Users
Advanced Practice Nurses
Nurses
Guideline Objective(s)

To provide evidence-based recommendations for Registered Nurses and Registered Practical Nurses related to the assessment and management of people with colostomies, ileostomies and urostomies, including the assessment and management of the peristomal skin

Target Population

All individuals with ostomies, across the continuum of care, including the needs of the family and caregiver

Interventions and Practices Considered
  1. Develop therapeutic relationship with client
  2. Comprehensive assessment including history and physical; psychosocial; and cultural, spiritual, and religious norms
  3. Consult with interdisciplinary team regarding assessment and intervention
  4. Design an individualized plan of care
  5. Preoperative care, including stoma site marking and relaxation therapy
  6. Postoperative care, including assessment of potential complications, colostomy irrigation
  7. Ostomy education for patients and family members
  8. Consult Enterostomal Therapy Nurses (ETNs), as appropriate
  9. Organization and policy recommendations and strategies directed at practice settings and the environment in order to facilitate nurses' practice
Major Outcomes Considered
  • Patient and family satisfaction
  • Functional status
  • Quality of life
  • Complication rate

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The search strategy utilized during the development of this guideline focused on two key areas. One was a structured website search to identify best practice guidelines published on the topic of ostomy care and management; and the second was a literature review to identify primary studies, meta analyses and systematic reviews published in this area from 1998–2008.

Guideline Search

One individual searched an established list of websites for content related to the topic area in December 2007. This list of sites was compiled based on existing knowledge of evidence-based practice websites, known guideline developers, and recommendations from the literature. Presence or absence of guidelines was noted for each site searched as well as date searched. The websites at times did not house guidelines, but directed to another website or source for guideline retrieval. Guidelines were either downloaded if full versions were available or were ordered by phone/email.

In addition, a website search for existing practice guidelines on ostomy care and management was conducted via the search engine "Google," using key search terms. One individual conducted this search, noting the results of the search, the websites reviewed, date and a summary of the results.

Panel members were also asked to review personal archives to identify guidelines not previously found through the above search strategy. The search strategy described above resulted in the retrieval of no guidelines on the topic of ostomy care and management.

Literature Review

A database search for existing evidence related to ostomy care and management was conducted by a University Health Network librarian. An initial search of the CINAHL, PsycInfo, Medline, and EMBASE databases for studies published from 1998 to 2008 was conducted in January 2008.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Level of Evidence

Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials

Ib Evidence obtained from at least one randomized controlled trial

IIa Evidence obtained from at least one well-designed controlled study without randomization

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization

III Evidence obtained from well-designed, non-experimental descriptive studies, such as comparative studies, correlation studies and case studies

IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

In January 2008, an international, multidisciplinary panel of nurses, and allied health professionals with expertise in practice, education and research on ostomy care and management from a range of practice settings was convened under the auspices of the Registered Nurses' Association of Ontario (RNAO).

The panel members discussed the evidence summaries and key articles and came to a consensus on the best available evidence on which to base recommendations. The panel then divided into subject matter expert subgroups for the purpose of drafting recommendations for nursing interventions. This process resulted in the development of practice, education and organization and policy recommendations. The panel members as a whole reviewed the draft recommendations, discussed gaps, reviewed the evidence and came to consensus on a final set of recommendations.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The draft guideline was submitted to a set of external stakeholders for review and feedback. Stakeholders represented various health-care professional groups, clients and families, as well as professional associations. External stakeholders were provided with specific questions for comment, as well as the opportunity to give overall feedback and general impressions.

The feedback from stakeholders was compiled and reviewed by the development panel – discussion and consensus resulted in revisions to the draft document prior to publication.

Recommendations

Major Recommendations

The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field. See the original guideline document for additional information provided in the "Discussion of Evidence."

Core Recommendations

Recommendation 1

Develop a therapeutic relationship with the client and family.

(Level of Evidence = III)

Recommendation 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.

(Level of Evidence = III)

Recommendation 3

Consult with interdisciplinary team members for assessment and intervention as needed for all clients requiring, or who already have, an ostomy.

(Level of Evidence = IV)

Recommendation 4

Design a mutually acceptable plan of care between the client/family and all health-care providers, which optimizes health and self-efficacy in ostomy management.

(Level of Evidence = III)

Practice Recommendations: Pre-Operative Phase

Recommendation 5

Pre-operative education should be provided to all clients and families requiring ostomy surgery.

(Level of Evidence = Ib)

Recommendation 6

Stoma site marking should be performed on all clients undergoing ostomy surgery.

(Level of Evidence = IIa)

Recommendation 7

Explore the potential impact of ostomy surgery on intimacy and sexual functioning with client/partner.

(Level of Evidence = 1a)

Recommendation 8

Progressive Muscle Relaxation Training (PMRT) should be offered to clients undergoing ostomy surgery as part of routine care.

(Level of Evidence = Ib)

Practice Recommendation: 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.

(Level of Evidence = IV)

Recommendation 10

Identify risk factors that influence stomal and peristomal complications.

(Level of Evidence = III)

Recommendation 11

Review the client's medication profile to ensure that maximum absorption and effectiveness will be achieved in relation to the type of ostomy.

(Level of Evidence = IV)

Recommendation 12

Avoid insertion of a glycerin suppository into a colostomy in order to aid evacuation of effluent.

(Level of Evidence = Ib)

Recommendation 13

Counseling by a Registered Dietitian should be performed for clients with an ostomy who are at risk for, or who develop, nutritional complications.

(Level of Evidence = IIa)

Recommendation 14

Prepare the client and family by teaching at least the minimum skill set specific to their needs prior to discharge from hospital.

(Level of Evidence = IV)

Recommendation 15

Discharge the client and family with home care support.

(Level of Evidence = Ib)

Recommendation 16

Ensure that the ostomy plan of care is individualized to meet the needs of the client and family.

(Level of Evidence = IV)

Recommendation 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.

(Level of Evidence = IIb)

Recommendation 18

Educate client and family members to recognize complications affecting the stoma and peristomal skin.

(Level of Evidence = IV)

Recommendation 19

Colostomy irrigation may be implemented as a safe and effective method for the management of descending or sigmoid colostomies for select adult clients.

(Level of Evidence = III)

Education Recommendations

Recommendation 20

Ostomy education for all levels of health-care providers should be a systematic, client-centred process, provided in both academic and workplace venues.

(Level of Evidence = IV)

Recommendation 21

Consult ETNs in the development of ostomy educational programs that target appropriate health-care providers, clients, family members and caregivers.

(Level of Evidence = IV)

Organization & Policy Recommendations

Recommendation 22

Organizations should utilize a credentialed ETN for policy development and program management.

(Level of Evidence = IV)

Recommendation 23

All clients with ostomies, and their families, should have access to comprehensive education.

(Level of Evidence = IV)

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.

(Level of Evidence = IV)

Recommendation 25

Practice settings must have access to an interdisciplinary team of knowledgeable and skilled health professionals to address quality care in ostomy management.

(Level of Evidence = IV)

Recommendation 26

Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes:

  • An assessment of organizational readiness and barriers to implementation, taking into account local circumstances.
  • Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process.
  • Ongoing opportunities for discussion and education to reinforce the importance of best practices.
  • Dedication of a qualified individual to provide the support needed for the education and implementation process.
  • Ongoing opportunities for discussion and education to reinforce the importance of best practices.
  • Opportunities for reflection on personal and organizational experience in implementing guidelines.

(Level of Evidence = IV)

Definitions:

Level of Evidence

Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials

Ib Evidence obtained from at least one randomized controlled trial

IIa Evidence obtained from at least one well-designed controlled study without randomization

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization

III Evidence obtained from well-designed, non-experimental descriptive studies, such as comparative studies, correlation studies and case studies

IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence is identified and graded for each recommendation (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Appropriate assessment and management of people with colostomies, ileostomies and urostomies
  • By promoting a standard of excellence in ostomy care through expert consultation, education and evidence-based best practice, clients benefit from the consistency and continuity of care delivery from all interdisciplinary team members.
Potential Harms

Not stated

Contraindications

Contraindications

Contraindications and precautions to medications for patients with ostomies are provided in Appendices H and O of the original guideline document.

Qualifying Statements

Qualifying Statements
  • These guidelines are not binding on nurses or the organizations that employ them. The use of these guidelines should be flexible based on individual needs and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses' Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work.
  • This nursing best practice guideline is a comprehensive document providing resources necessary for the support of evidence based nursing practice. The document needs to be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client. Guidelines should not be applied in a "cookbook" fashion but used as a tool to assist in decision making for individualized client care, as well as ensuring that appropriate structures and supports are in place to provide the best possible care.
  • The guideline is divided into practice phases in order to present the complexity of the care issues and needs of the client in a logical manner. The development panel would like to impress upon the reader that the care and management of clients who have ostomies is not linear, and that the frequently changing needs of the client must be reflected in a highly flexible, yet comprehensive plan of care delivery. The phases represent the client's unique journey, and often overlap.

Implementation of the Guideline

Description of Implementation Strategy

Best practice guidelines can only be successfully implemented if there are: adequate planning, resources, organizational and administrative support as well as appropriate facilitation. In this light, Registered Nurses' Association of Ontario (RNAO), through a panel of nurses, researchers and administrators has developed the Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding the implementation of any clinical practice guideline in a health care organization.

The Toolkit provides step-by-step directions to individuals and groups involved in planning, coordinating and facilitating the guideline implementation. Specifically, the Toolkit addresses the following key steps in implementing a guideline:

  1. Identifying a well-developed, evidence-based clinical practice guideline.
  2. Identification, assessment and engagement of stakeholders.
  3. Assessment of environmental readiness for guideline implementation.
  4. Identifying and planning evidence-based implementation strategies.
  5. Planning and implementing evaluation.
  6. Identifying and securing required resources for implementation.

Implementing guidelines in practice that result in successful practice changes and positive clinical impact is a complex undertaking. The Toolkit is one key resource for managing this process. The Toolkit can be downloaded from the RNAO Web site.

Evaluation/Monitoring of Guideline

Organizations implementing the recommendations in this nursing best practice guideline are advised to consider how the implementation, and its impact, will be monitored and evaluated. A table found in the original guideline document, based on a framework outlined in the RNAO Toolkit: Implementation of Clinical Practice Guidelines provides an example of how this matrix from the Toolkit may be used.

Implementation Tools
Chart Documentation/Checklists/Forms
Foreign Language Translations
Mobile Device Resources
Patient Resources
Tool Kits
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Registered Nurses' Association of Ontario (RNAO). Ostomy care and management. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2009 Aug. 115 p. [101 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Aug
Guideline Developer(s)
Registered Nurses' Association of Ontario - Professional Association
Source(s) of Funding

Funding was provided by the Ontario Ministry of Health and Long-Term Care.

Guideline Committee

Guideline Development Panel

Composition of Group That Authored the Guideline

Development Panel Members

Kathryn Kozell, RN, MScN, APN(AC), CETN(c)
Team Leader
Past President, CAET
Coordinator of Quality Initiatives
London Health Sciences Centre
London, Ontario

Helen Abrams, RD, CNSD
Registered Clinical Dietitian
University Hospital
London Health Sciences Centre
London, Ontario

Patti Barton, RN, PHN, CETN(c)
Clinical and Education Lead
Specialty ET Services
Toronto, Ontario

Nancy Bauer, HBA, HB Admin, RN, ETN
RNAO Champion Facilitator
Registered Nurses' Association of Ontario
Toronto, Ontario

Ruth Best, RN, BA, ETN
Skin Wound, Ostomy Nurse Clinician
London Health Sciences Centre
London, Ontario

Karen Bruton, RN, BScN(c), ETN
Clinical Resource Nurse
Northumberland Hills Hospital
Cobourg, Ontario

Helen Fatum, RN, BScN, ETN
Enterostomal Therapist/Patient Educator
North Bay General Hospital
North Bay, Ontario

Louise Forest-Lalande, RN, MEd, ETN
Consulting Manager in Nursing Sciences
CHU Sainte-Justine
Montréal, Québec

Dr. Mikel Gray, RN, PhD, FNP, PNP, CUNP, CCCN, FAANP, FAAN
Professor, Nurse Practitioner
Department of Urology and School of Nursing,
University of Virginia
Charlottesville, Virginia, USA

Connie Lynne Harris, RN, MSc, ETN
Senior Clinical Specialist: Ostomy Wounds
CarePartners
Waterloo, Ontario

Virginia McNaughton, RN, MPA, CETN(c)
Advanced Practice Consultant
Wound, Ostomy, Continence
Saint Elizabeth Health Care
Markham, Ontario

Debbie Miller, RN, BScN, MN, APN(AC), CETN(c)
Ostomy Specialty Practitioner
Sunnybrook Health Sciences Centre
Toronto, Ontario

Susan Mills-Zorzes, RN, BScN, MDE, CWOCN, CETN(c)
Director, CAET Enterostomal Therapy
Nursing Education Program; Enterostomal Therapy Nurse
St. Joseph's Care Group
Thunder Bay, Ontario

Nancy Parslow, RN, CETN(c)
Wound Specialty Nurse
Southlake Regional Health Centre
Newmarket, Ontario

Colleen Simpson, RN, BScN
Staff Nurse
Elm Grove Living Centre
Toronto, Ontario

Samantha Mayo, RN, MN
Research Assistant
Registered Nurses' Association of Ontario
Toronto, Ontario

Rishma Nazarali, RN, BScN, MN
Program Manager, Best Practice Guidelines
Registered Nurses' Association of Ontario
Toronto, Ontario

Catherine Wood, BMOS
Program Assistant
Registered Nurses' Association of Ontario
Toronto, Ontario

Financial Disclosures/Conflicts of Interest

Declarations of interest and confidentiality were made by all members of the guideline development panel. Further details are available from the Registered Nurses' Association of Ontario.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in English and French in Portable Document Format (PDF) from the Registered Nurses' Association of Ontario (RNAO) Web site.

Print copies: Available from Registered Nurses' Association of Ontario (RNAO), Nursing Best Practice Guidelines Project, 158 Pearl Street, Toronto, Ontario M5H 1L3

Availability of Companion Documents

The following is available:

  • Toolkit: implementation of clinical practice guidelines. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2002 Mar. 91 p. Available in Portable Document Format (PDF) from the RNAO Web site. See the related QualityTool summary on the Health Care Innovations Exchange Web site.

Print copies: Available from the Registered Nurses' Association of Ontario (RNAO), Nursing Best Practice Guidelines Project, 158 Pearl Street, Toronto, Ontario M5H 1L3

Additionally, a variety of implementation tools, including a sample ostomy teaching record, sample assessment form, and ostomy teaching flow sheets are available in the original guideline document.

Mobile versions of RNAO guidelines are available from the RNAO Web site.

Patient Resources

The following is available:

Print copies: Available from the Registered Nurses Association of Ontario (RNAO), Nursing Best Practice Guidelines Project, 158 Pearl Street, Toronto, Ontario M5H 1L3.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This summary was completed by ECRI Institute on July 14, 2010. The information was verified by the guideline developer on September 16, 2010.

Copyright Statement

With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety only, in any form, including in electronic form, for educational or non-commercial purposes, without requiring the consent or permission of the Registered Nurses' Association of Ontario, provided that an appropriate credit or citation appears in the copied work as follows:

Registered Nurses' Association of Ontario 2009. Ostomy care and management. Toronto, Canada: Registered Nurses' Association of Ontario.

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