WOC is actually an acronym for three words – wound, ostomy, continence – and WOC nurses must complete a formal, accredited WOC training program and pass a national exam in the field of trauma, ostomy, and continence.
WOC nurses with a comprehensive body of knowledge provide direct care to patients with abdominal stomas, wounds, fistulas, drains, pressure sores, or fecal incontinence through their in-depth nursing knowledge and skills, and are an important part of the treatment team for patients with IBD.
I. Preoperative Preparation
Once a patient agrees to surgical treatment, there is the potential for fecal diversion (stoma) and the patient should schedule a preoperative consultation with the WOC nurse.Preoperative education by the WOC nurse is closely related to the patient’s long-term postoperative adaptation to the stoma. The preoperative WOC nurse visit to the patient is the beginning of a cooperative relationship between the patient and the WOC nurse. Once the patient knows what a stoma is, the importance of choosing a stoma location is then explained to the patient. The right stoma position can improve the patient’s ability to care for himself/herself and resume daily activities as soon as possible.
Second, the following factors should be noted when choosing the stoma location.
1. the location of the stoma needs to pass through the rectus abdominis muscle to avoid the occurrence of a hernia
2, the stoma area should have at least 2.5 inches of flat skin in diameter, avoiding skin folds and bone protrusions, which helps to maintain the airtightness of the stoma bag.
3. The stoma should be within the patient’s visual range for self-care.
III. Surgical considerations
The surgical technique of stoma plays an important role in the success of stoma management. The stoma is usually 2-2,5 cm above the skin, which allows the stool to flow smoothly into the stoma bag and maintain its airtightness; if the stoma is at the same level as the skin, the output stool will destroy the airtightness of the stoma bag and damage the skin around the stoma, leading to the failure of the stoma.
IV. Early postoperative care
After stoma surgery, a clear visual stoma bag is first placed around the stoma, which facilitates the medical staff to assess the integrity of the stoma and fecal output. At 24 to 48 hours postoperatively, the stoma begins to appear functional. The primary sign of return of bowel function is the entry and bulging of intestinal gas into the stoma bag.
The patient will hear a sound as the intestinal gas passes through the stoma. This is due to stoma edema, but the sound will disappear as the edema subsides, so the patient should not be too concerned. The stoma should be evaluated every 8 hours for 24 hours after surgery for signs of necrosis. When the stoma becomes black, necrosis is likely and necrosis at or below the fascia is an indication for emergency surgery.
V. Patient education
Patients need to learn two skills, the first is to learn to empty the stoma bag and the second is to learn to change the stoma bag. In order to shorten the length of stay, patients who need an ostomy are taught how to master the above skills starting on the first postoperative day. Since the patient is not competent enough to learn this skill after surgery, it is wise to educate his guardians at the same time, who can be involved in patient education later.
When the patient’s bowel function is restored, the patient needs to cooperate with the staff in emptying the ostomy bag. In the hospital, the excrement from the ostomy bag should be emptied into a measuring container so that the amount of excretion can be measured. When the patient is at home, they should sit on the toilet and drain the contents of the stoma bag from between their legs in order to observe how much water is in the bag. Clean the end of the ostomy bag immediately after emptying it. The stoma bag should be emptied when the excrement reaches one-third of the bag to prevent the bag from being pulled off by excessive fecal weight.
Patients can visit the WOC Nurse Clinic approximately every 3 weeks after discharge to assess the recovery of the stoma and the integrity of the surrounding skin, and to help patients choose the most appropriate stoma bag for their stoma condition.
VI. Stoma bag
The ostomy bag consists of three parts, the skin barrier, the waterproof adhesive, and the collection device.
1, the skin barrier is an important part of the ostomy bag, it ensures the adhesive closure of the ostomy bag and protects the skin around the stoma, the skin barrier is composed of several materials: including water-like gum (to absorb moisture from the skin surface and maintain a good airtightness), polymer materials to maintain adhesion and adhesion enhancers. The skin barrier is surrounded by a waterproof material (usually tape) that keeps the wearer’s stoma moist while preventing the stoma bag from loosening from the skin.
2.The stoma bag is used to collect metabolic products and it comes in many types, the type chosen depends on the amount of stoma output and the patient’s preference.
3, For a patient with a fecal diversion, the average wearing time of an ostomy bag is 4 days, and for most strong skin barriers, when it comes in contact with feces its erosion is slow. A patient with a high stoma discharge has a faster erosion rate of the skin mucosal barrier than a patient with a low discharge.
The WOC nurse should closely observe and assess the patient’s actual condition and determine the best time to wear the ostomy bag. When the patient perceives an abnormal smell, a problem with the airtightness of the stoma bag should be considered.
VII. Adaptation issues
In most cases patients can successfully adapt to life with a stoma if they are adequately educated in self-care and if they have access to appropriate psychological support.
Other issues that need to be addressed for a new stoma patient include: clothing wear, daily activities, sexuality, etc. Many patients with a stoma will need to make adjustments in their style of dressing. If the stoma is below the waistline, the clothing worn should be comfortable and soft to keep the stoma pouch flat so that stool is evenly distributed in the pouch; if the stoma is above the waistline, upper body undergarments can be tucked into the waistband which helps the pouch stay flat. There are no special adjustments needed for the daily life of the stoma holder. The adhesive of the ostomy bag is waterproof, allowing the patient to shower or even swim with the ostomy bag on.
There are no special dietary requirements for stoma patients (except for a low residue diet for 4-6 weeks after surgery); there are no special or modified physical activities, and daily activities such as skiing, tennis, etc. can be performed as usual.
VIII. Stoma and peristoma complications
The most common problem encountered by stoma patients is leakage, loss of airtightness around the stoma, leakage of stool under the skin barrier and thus contact with the skin.
ix. This problem occurs mainly due to the following reasons.
1. mismatch between the size of the opening of the skin barrier and the size of the stoma.
2. inappropriateness of the type of skin barrier to the skin around the stoma.
3. prolonged wearing time when the skin barrier has eroded thus resulting in fecal contact with the skin. Solving this problem requires checking that the size, type, and wearing time of the current ostomy bag is optimal. The patient should seek assistance from the WOC nurse who will provide a solution.
Once the best ostomy bag has been determined, the eroded skin around the stoma can be treated with powders that will keep the skin dry and promote skin mucosa repair.
Separation of the skin mucosa is also a common complication after stoma surgery. Malnutrition and long-term use of hormones are risk factors for poor healing of the stoma skin mucosa.
X. When skin-mucosal separation is found to be unavoidable, treatment measures include.
1. filling the cavity with a skin barrier powder to promote wound healing.
2. trimming part of the skin barrier of the ostomy bag to protect the skin in the area.
Peristoma skin gangrenous pyoderma (PPG) is a rare ulcerative skin disease of unknown etiology that occurs in the skin around the stoma. It initially presents with one or more pustules and then forms an irregular, rough, still well-defined full-thickness ulcer.