Providing education for self-care along with encouragement and support to an individual undergoing ostomy surgery is an essential intervention for the Certified Ostomy Care Nurse (COCN).1 Hospital lengths of stay after surgery continue to decrease, enhancing the need for preoperative education for patients who expect to undergo ostomy surgery.2 Expert professional associations, such as the Wound Ostomy Continence Nurses Society, the United Ostomy Associations of America, and the American Society of Colon and Rectal Surgeons, recommend that all patients preparing for fecal or urinary diversion receive preoperative education.3 Current best evidence indicates that stoma site marking and preoperative education decrease the risk for stomal and peristomal complications and enhance health-related quality of life in patients undergoing stoma surgery.2,3 Whenever possible, family or caregivers should be included in education that includes the definition of an ostomy, appearance, and function; the process and benefit of surgical site marking; an overview of the surgical procedure; and postoperative stoma management.
Planning for surgery should include a preoperative visit with the CWOCN, CWON, or COCN. A family member or caregiver should also be encouraged to attend the preoperative appointment with the patient. Various education techniques may be used for teaching, including one-on-one verbal instruction, multimedia educational sources, patient testimonials, and valid Web resources.3 These high-quality resources are cost-effective, readily accessible, and extend educational support to patients and families. When providing patient education, the COCN should assess the patient and family's health literacy and learning styles.
When creating an educational plan, the COCN should include diagnosis, type of surgical procedure, patient comprehension of the plan, pertinent physical needs, support system involvement, and any educational limitations.3 Before the educational assessment, the COCN should be aware of the patient's prognosis and expected course of care. The plan should address cultural, religious, and/or special needs related to employment.
Patients and their caregivers should be encouraged to ask questions and share any prior knowledge along with any concerns; this approach fosters an environment that will reduce unnecessary fears or misconceptions.3 In addition to educating on ostomy care, postoperative education should address incision(s) location(s); the presence of catheters, tubes, and/or drains; pain management; status of oral intake; and importance of early ambulation.1 The COCN often uses the teach-back method to evaluate patient understanding by asking the patient and family members to explain the aspects covered in their own words.3 Evaluating patient understanding allows the COCN to clarify concepts as needed. Patients who feel well prepared for surgery are more likely to experience less peristomal skin complications and leakage and adjust to their ostomy along with related self-care.2,3
When providing postoperative teaching and support, the COCN will again assess the patient's learning needs, abilities, preferences, and readiness to learn. Cultural considerations such as religious practices and language barriers, the patient's motivation to learn, along with emotional and financial barriers are included when assessing the patient's needs.1 This allows postoperative education to be individualized to the patient. Any family members whom the patient would like to receive instruction should be included in teaching as they may need to assist with ostomy care after the patient is discharged from hospital.
Patient education regarding their new ostomy will continue postoperatively. Education focusing on self-care and activities of daily living is vital before being discharged from hospital.4 The first postoperative pouch change with the COCN allows the patient to learn basic pouching practices. This includes becoming familiar with the type of pouching system and any accessories used. It is essential to instruct the patient to have all the needed supplies at hand before removing their pouch. During the pouch change, the patient will learn how to assess their peristomal skin for any signs of damage. Patients should be taught how to measure their stoma and cut the skin barrier's opening to fit. The stoma's size will decrease as the patient heals from their surgery. The patient will need to continue to measure their stoma 4 to 6 weeks postoperatively. Necessary skills for the postoperative ostomy patient include manipulating the pouch opening and emptying their pouch. The patient should also be taught when to empty their pouch and how often it should be changed. Hospital discharge instructions include steps for emptying and changing the pouch, a list of ostomy products used, ordering supplies, scheduling follow-up appointments, and when to seek medical attention.
After hospital discharge, patients may receive home health nursing visits. The COCN in the home health setting will continue to provide education and support with a shift in focus toward living with a stoma. As the patient adjusts to their life with a stoma, attention may be directed toward lifestyle needs such as clothing, physical activities, dietary concerns, and sexual issues.
The COCN is integral in providing education and support along a continuum of care ranging from preoperative through postoperative follow-up and the life span of the ostomy. The American Society of Colon and Rectal Surgeons asserts that patients who have ostomies should have access to an ostomy nurse for follow-up care as needed.4 The United Ostomy Associations of America also endorse the need for patients to have access to an ostomy nurse in their Ostomy and Continent Diversion Patient Bill of Rights.5 The statements from both organizations illustrate the need for having WOCNCB certified ostomy nurses in multiple settings of care, including ambulatory, home health, long-term, and acute care.
COCN Examination Questions
1. The COCN is rounding on a 62-year-old inpatient who underwent a Hartmann's procedure for a tumor 3 days ago. When the ostomy nurse enters the patient's room, they notice the patient is crying. The patient reports that “something is wrong” because she just wiped a clear “gooey” liquid from her rectum. What is the COCN's best initial response to this current situation?
- “This is a concern. I will notify your surgeon immediately.”
- “This is normal. The intact portion of your lower bowel continues to produce mucus that can pass through your rectum even with this type of colostomy.”
- “Some patients suggest using gauze or a sanitary napkin worn in their underwear to help catch unexpected leaks.”
- “If the mucus begins to have an odor, please promptly notify us.”
Rationale: A Hartmann's procedure (proctosigmoidectomy) is frequently performed for patients with diverticulitis, cancer, trauma, or other types of bowel inflammation. The surgeon will remove the inflamed colon and reroute the proximal and healthy segment to a colostomy. The distal portion of the unaffected anorectal section is surgically closed and left as a “rectal stump.” In this case scenario, the patient is distressed by their anal discharge. The COCN's response is based on knowledge that the bowel continues to secret mucus as a natural physiological function, and episodes of mucus discharge from the anus are anticipated and normal from the intact distal rectal stump.
Given that a Hartmann's procedure is often performed as emergency surgery, this patient may not have received preoperative teaching on this topic or may not recall this portion of these teaching. The COCN provides additional teaching on this subject based upon their individual readiness to learn. In this case, the first response by the COCN should focus on alleviating the patient's immediate fears by explaining that this is a typical finding with this type of procedure. This makes letter B the correct answer. The first option in letter A would not be appropriate as this is a normal finding. The last 2 distractors (C and D) are accurate, but they do not provide the most appropriate response to the patient's question. The information in distractors C and D should likely follow in the patient's subsequent ostomy nurse's instructions.
Content outline: Ostomy Domain III: Task 1; Knowledge: 030101 and 030102; Skill: 030108
Cognitive level: Recall
2. The COCN is planning preoperative education for an obese patient scheduled to have a total proctocolectomy with Brooke ileostomy for refractory ulcerative colitis. What is the best description of how to site for the stoma marking for this patient?
- Mark stoma on the upper aspect of the abdominal skinfold within the patient's line of sight.
- Mark stoma on the underside of the abdominal skinfold within a crease of the rectus abdominis.
- Mark stoma on the underside of the abdominal skinfold within a crease outside the rectus abdominis.
- Mark stoma 2 cm above the umbilicus and 5 cm below the patient's left upper quadrant.
Rationale: To optimize future pouching needs, it is best practice to have a COCN meet with the patient before a surgery that will result in an optimal stoma placement. In obese abdomens with large skinfolds, finding an appropriate position to accommodate a satisfactory surface area for the postoperative appliance may be challenging. The key to the ideal placement of the site marking is to ensure that the patient can both visualize and perform routine care to the impending stoma and appliance apparatus. In individuals with large abdomens, the COCN will want to ensure that the stoma is placed on the upper aspect of a protruding skinfold in which the location is in the patient's line of sight. Therefore, the correct answer is A. In addition, placement of the site marking within the borders of the rectus abdominis muscle is standard practice. In these answer selections, distractor B correctly identifies the positioning within the rectus abdominis. However, distractors B and C are erroneous because they indicate that the underside of the abdominal fold should be chosen and within a skin crease. The underside of a large bulging skinfold is not a suitable location to place the stoma as this could make it very difficult for the patient to see or even reach the stoma area.
Furthermore, any deep crease of the abdomen should be avoided as it may interfere not only with the patient's visualization of the stoma and appliance but also with potential adhesive adherence and appliance security, leading to potential peristomal complications. Distractor D is incorrect as measurements of this kind do not exist as distinctive landmarks with stoma marking. Ideally, it is best to leave at least a 5-cm distance away not only from the umbilicus but also from skin scars, folds, hernias, wrinkles, radiation sites, or other obvious areas of skin insult or damage.
Content Outline: Ostomy Domain III: Task 1; Knowledge: 030101
Cognitive level: Application
COCN-AP Examination Questions
3. A 49-year-old patient with a new ileostomy is being seen in the surgeon's office by the COCN practitioner for his 1-week postdischarge appointment. The COCN-AP is planning to order some routine lab work to assess the patient's status. Which of the following lab values would be the most important ones to evaluate at this visit?
- No labs are necessary today
- Phosphorus; LFTs
- BMP; magnesium
- CRP; ESR
Rationale: A patient may be at risk for developing high output from their stoma after having a new ileostomy placed. The output amount is worrisome when it exceeds 2 L in 24 hours, although there is some debate surrounding this cut point. It is estimated that 16% of patients with a stoma will acquire this condition called high-output stoma, leading to potential complications with dehydration, nutrition, and electrolyte imbalances. For this reason, it is essential for the COCN-AP to assess the patient for potential signs and symptoms of dehydration. Since this is the patient's first postoperative visit after being discharged from the hospital, it is an appropriate time to obtain blood work to assess for hydration and electrolyte balance. Therefore, the correct answer is letter C and distractor A (no blood work is needed) is incorrect. Obtaining a basic metabolic panel (BMP) allows the CONC-AP to evaluate serum electrolytes and renal function. Elevated serum sodium, blood urea nitrogen (BUN), and creatinine levels could indicate dehydration. In addition, the serum magnesium should be evaluated because magnesium losses occur with chronic diarrhea. The other distractors, B and D, are not relevant to this current prioritization of assessment findings.
Content outline: Advanced Practice—Ostomy Domain 3A: Task 1; Planning: 030100
Cognitive level: Analyze
4. As a hospital-based COCN-AP, you are following a 60-year-old male patient recovering well after undergoing a radical cystectomy with construction of an orthotopic neobladder. He is assessed on postoperative day 4, and there have been no complications. What specific vitamin/mineral supplementation would the COCN-AP teach the patient to possibly plan for in the future?
- Vitamin B-12
Rationale: A cystectomy with an orthotopic neobladder procedure is most often performed due to the result of bladder cancer. The diseased bladder is entirely removed. A neobladder reconstruction is created as one alternative for continent urinary diversion in patients who are appropriate for this procedure. After the bladder is removed, the new pouch (or reservoir for future urine collection) is formed from a piece of the patient's terminal ileal segment. One end of this intestine will be connected to the ureters and the other to the urethra. The patient can retain continence with this “artificial” pouch. The mechanisms of pouch emptying are not entirely understood; they appear to rely on contractions of the detubularized bowel, along with contraction of the abdominal muscles and simultaneous relaxation of the pelvic floor muscles. Since a segment of the ileum is used to develop the new pouch, the patient is at an increased risk for vitamin B-12 deficiency due to the new disturbance of the terminal ileum's absorption. Vitamin B-12 deficiencies can lead to anemia and further cardiovascular and neurological complications. The only receptors to absorb the intrinsic factor–vitamin B-12 are found in the terminal ileum. The correct answer is letter D. Magnesium and copper are primarily absorbed in the duodenum, making distractors A and C incorrect. Zinc is absorbed throughout the whole intestine, with the highest amount of absorption occurring in the duodenum and ileum, which makes distractor B incorrect as well. Fortunately, and on a positive note, the incidence rate of vitamin B-12 deficiency in this patient population group is relatively low. Nonetheless, the patient will need to be monitored for vitamin B-12 deficiency over time since hepatic stores of this vitamin may take as long as 3 to 5 years to be exhausted.
Content outline: Advanced Practice—Ostomy Domain 3A: Task 1; Planning: 030100
Cognitive level: Recall