It may come as a shock to caretakers of the patient that discharge planning may commence as soon as a patient has been admitted. This does not necessarily mean that the patient is being released for home, but rather it means that plans are being put in place for a successful discharge plan to take place. Information is gathered about the patient, how they live, for example, do they live with others, are they dependent or independent (Birjandi & Bragg 2009). Caretakers are actively involved in a discharge plan provided the patient gives consent. Once the patient shows improvement, it is clear that further recovery in a hospital set-up is not likely to take place and thus they are sent to an environment they may adopt to their needs; their home.

Birjandi, A & Bragg, (2009) say that discharge planning is essential and should be done right, whether the discharge is to a rehabilitation center, a nursing home or the client’s home. Medical practitioners should have an ideal discharge plan as studies have shown that improvement in hospital discharges with great outcomes when appropriate discharge plans are made.

Healthcare givers, family members and patients themselves have a great role to play after discharge in maintaining good health. Even though discharge planning is essential in patients’ health there is inconsistence in both the discharge process and the quality of discharge planning in most of the health care system.

In this paper, we shall look at a discharge plan for a client with the cerebral vascular accident from hospital to their home. We shall look at initial assessment of the client at the time of admission; determine the possible discharge needs, family involvement in decision making and how to transport the client to their destination.

Birjandi, A & Bragg, L. (2009) describe discharge planning as a method used to decide the requirements of a patient as they shift from one level of care to another, only doctors may approve patients release from a health facility, but the actual discharge plan may be done by a nurse, case manager, case manager. Complicated conditions such as cerebral vascular accident may have a team approach. Well organized discharge planning may reduce the chances of re-hospitalization and aid in recovery; ensure medications are well prescribed and administered correctly. In general a discharge plan should involve the following; evaluation of the client by qualified practitioner, discussion with both the client and the caregiver, planning of the transfer process and homecoming of the client, determining whether the caretaker needs more training or any other kind of support, referral to support an organization or care agency and finally arranging for follow up activities.

In our case we shall look at Ms. Kate a 76 year-old female who was admitted from the emergency department with a diagnosis of Right Cerebra Vascular Accident. Her Past Medical History includes: hyperlipidemia, hypertension, osteoarthritis, and osteoporosis.

Neurological:

left-sided weakness for the past 2 days, awake, alert, and oriented to person, place, and time. Denied swallowing difficulties, no visual defects and denied pain.

Medications: Aspirin 81mg per oral daily; Tylenol 650mg per oral when necessary for pain;

Cerebral vascular and pulmonary:

Placed on a cardiac monitor, findings indicated normal sinus rhythm. Vital signs taken every 4 hours, pulse 82; blood pressure 168/64; respirations 20. Lung sounds were clear to auscultation bilaterally. Oxygen Saturation on room air 97%.

Gastrointestinal:

Abdomen soft, non-tender, not distended, positive bowel sounds. Bowel movement present

Genitourinary:

Voids freely, requiring assistance to the bathroom. Output approximately 1000ml/day. Brief episode of dysuria on admission.

Integumentary:

skin intact, no lesions noticed

Musculoskeletal:

Active range of motion right side; limited range of motion on the left side; required assistant to get into a wheelchair. History of recent balance problems.

Psychosocial:

lives with daughter in a two story home; occupation: retired teacher

Discharge needs were discussed with the caretaker, these included the physical condition of the family before and after hospitalization, the details of the kind of care required by the client were discussed, included information of the patients prognosis, what activities she might need to help with; information about the clients medication and diet should be given, any extra equipment that was deemed necessary such as wheelchair, oxygen and who will be in charge of the clients meal preparation, transport to referrals and support groups.

The daughter who lives with Mr. Kate was involved in the discharge process, her ability and willingness to provide care to her mother was assessed, and the results were as follows; she felt it was too early for her discharge, as she did not have time to spare to take care of her mother as her work was demanding. She also had concerns about she would go about transporting her mother from the bed to her chair and taking her to the bathroom. She was referred to help agencies that assist in taking care of patients at their homes at a paid fee. Several agency information was availed to her, with instructions to come up with a decision on which one to use. She was also given a choice to hire an individual at a fee or hire nurses or case managers or other persons familiar with the condition.

Ambulance services were given as an option to transport the patient to their home at a small fee at the time of discharge or the client may use assisted transport to their homes, wheelchair or stretchers were suggested be used for our client as she could walk with assistance. This was done in advance and the patient was fully responsible for this kind of transport arrangement.

Discharge planning varies according to the hospital set up and the person who initiates it, and what kind of follow-up is needed, and whether the care takers are assessed for their ability to cater for the client’s needs. The transition of care and discharge planning all centered on improving the quality of care administered to a client, for example, education the care givers and training them on the conditions of their patients, encouraging preventive care and including caretakers to be part of the health care team. Simple steps such as exchanging patient’s progress regularly with the doctors or the health team increase the chances of effective follow up care. Telephone conversions, post discharge with doctors also helps to anticipate problems and improve care at home.

Corey, G., Corey, M., & Callanan, P. (2003) suggest that relative to discharge planning with some patient, there may be underlying issues that contribute to ethical dilemmas. As case managers, we should take reasonable steps to safeguard the interests and rights of those clients. Ethical dilemma occurs when an individual has to choose between two or more conflicting ethical standards. There is no one right answer and there is no easy answer! Codes of ethics provide guidelines, but don’t necessarily tell us what to do. Using a hierarchical ethical decision-making approach can help you achieve an acceptable resolution. Mattison, (2000) reminds us that utilizing an ethical decision-making model doesn’t result in bias-free decisions. Our values still come into play utilizing an ethical decision-making model and we may not be aware of it! First of all, it is important to remember clients’ rights to self determination and autonomy – clients have the right to make poor decisions. However, the role of the case manager is different in this situation depending on the client’s cognitive capacity for decision making. If the client has capacity, the focus is on ensuring the client is making an informed decision and reassuring the care team, which includes the family, about resources to maximize safety. If the client does not have capacity, the focus is identifying someone who can act on the client’s behalf and exploring alternatives for creating a safe discharge in respect of the client’s wishes. For the client

When the care team perceives discharge unsafe; Promote informed consent – this involves educating the client about the team’s concerns related to his or her safety and potential consequences associated with an unsafe discharge. Review and encourage the use of resources to maximize safety, this involves identifying the services the client will need in a lesser care environment for the discharge to be successful. For the care team May not be aware of resources available to enable older adults to live safely in their own homes; reviewing these resources can eliminate concerns. May be worried about remote dangers that should not trump client autonomy and self determination, i.e. “If there was a fire, he would have difficulty escaping.”

When the care giver does not appear able to provide care. Sometimes family members or other caregivers wish to care for a client in a lesser care environment, but there are concerns about their ability to do so. In this situation, family/caregiver education is an important intervention.

When the caregiver does not seem able to provide care; Approaches to family/caregiver education: Convene a team conference with them to review the client’s level of care and specific care needs. Have the individual assume full responsibility for care for a period of time while in a safe environment (i.e. Work a 4-hour shift as his/her loved one’s caregiver in the nursing home so he/she is fully informed of what to expect in terms of career. Often this will result in the family member realizing for themselves that the care is too much and they will either not be able to do it or will need to have outside support. Alternatively, sometimes family members will actually do well, relieving the team’s fears about their ability. Try a short trial visit in the lesser care environment, say 24-48 hours, with a planned return to the higher care setting to debrief re: problems encountered.

When a client or caretaker refuses necessary service; again, it is important to remember clients’ rights to self determination and autonomy – clients have the right to make poor decisions. However, sometimes what seems to be a “poor” decision is based on misinformation or other concerns; it is important for case managers to explore factors contributing to the refusal of services deemed necessary by the care team. Potential factors contributing to service refusal; Cost; sometimes clients and their families don’t feel recommended services are (or will be) affordable. Have referred agency review associated costs with them; sometimes services are not as much as anticipated. Assist client/family to access sources of financial support such as Medicaid. Reframe costs as in terms of future savings, i.e. Paying a little for care now will prevent costly hospitalizations in the future. Discomfort with the thought of strangers in the home. Validate this concern; it is uncomfortable having unfamiliar people help with intimate tasks in one’s private domain. Arrange for client/family to meet potential service providers ahead of time to minimize anxiety.

Additional factors potentially contributing to service refusal; misunderstandings regarding the purpose of recommended services. Feelings of guilt or shame related to not being able to provide all care independently. Recommended services don’t fit client/family’s cultural belief system. Past negative experiences with similar services

Caretaker unwilling to have client return home; this is one of the most heart-wrenching ethical dilemmas to deal with and can bring up many issues of counter-transference; good self-care and supervision is important. Things to keep in mind; Client has a right to return to his or her own home, caretaker has a right not to provide care if this is something he or she is uncomfortable with, There may be a history of domestic violence or other traumatic relationship issues contributing to spouse/partner’s reluctance, Spouse/partner may be unaware of support services available to assist with care management and that the Client may be at risk for elder abuse.

For clients with capacity, living environments deemed “unsafe” may simply represent differences in lifestyle choices between client and the care team. For example, client’s home is cluttered, smells like cats, and there are dirty dishes and dust everywhere, but is not actually hazardous in any way. Case manager’s role: advocate for clients and educate them, offer services to assist client with home management. If home is in disrepair, infested with rats, covered with mold and rotting garbage hazardous situation indicative of deeper problems. Case manager’s role: further assessment regarding client’s capacity and whether interventions can make home livable; recognize that sometimes it is just not possible for clients to return home

We may conclude by stating that effective discharge planning and transitional care have real benefit in improving the out-come of a patient and bringing down the rate of re-hospitalization of the same patients.

Reference

Birjandi, A., & Bragg, L. (2009). Discharge planning handbook for health care: Top 10 secrets to unlocking a new revenue pipeline. Boca Raton: CRC Press.

Corey, G., Corey, M., & Callanan, P. (2003). Issues and ethics in the helping professions, 6th edition. Pacific Grove, CA: Brooks/Cole.

Mattison, M. (2000). Ethical decision-making: The person in the process. Social Work, 45 (3), 201-212.

Topic: Is the rise in Childhood Obesity a result of a sedentary lifestyle or due to pre-disposing factors?

Executive Summary

This review examines the relationship that predisposing factors and sedentary lifestyles have on childhood obesity. The authors of the article “Childhood Obesity: Trends and Potential Causes, state that there is not just one factor that is responsible for the high rates of childhood obesity. The authors conclude that, “Many complementary changes have simultaneously increased children’s energy intake and decreased their energy expenditure” (Anderson, 2006).

Numerous programs and research has been done in efforts to reduce the incidence rates of children with obesity. In order to better control this epidemic we must raise awareness around issues related to childhood obesity. Predisposing factors and sedentary lifestyles play an important role in the rising incidence rates of childhood obesity. However, one cannot attribute this rise solely to either one of these contributing factors.

Problem Statement

America has always been known for the sedentary lifestyles of its overweight citizens. Despite hundreds of advertised diets and work out programs, America is still leading the nation in the number of people who are obese (Obesity Statistics, 2010). Why would one want to eat healthy when it’s less expensive to eat unhealthy, and so easy to skip workouts? Technological advances have caused Americans to embrace a lifestyle that nurtures obesity. Children no longer play outside, they now spend hours watching TV and playing video games.

Background

“Daily participation in school physical education among adolescents dropped 14 percentage points over the last 13 years – from 42% in 1991 to 28% in 2003.26 In addition, less than one-third (28%) of high school students meet currently recommended levels of physical activity” (Contributing Factors , 2009). About a quarter of children in the U.S. are overweight and approximately 1/10 are obese (Akhtar-Danesh, Dehghan, & Merchant, 2005). Research done regarding twins reveals that genetic factors can contribute to obesity (Bouchard & Loos, 2003).

Obesity in adults can lead to major medical issues that can increase morbidity.. Childhood obesity has a strong linkage to adult obesity. (Speiser et. al, 2005)

Framework

The theoretical approach for this paper was based on the Health Belief Model. The Health Belief Model states that people have to be inspired in order to alter their behaviors (National Cancer Institute , 2005). In order to decrease the number of obese children in America, children must be motivated to change their behaviors. These include behaviors that put them at risk for obesity. They must feel inspired to lose weight by altering their lifestyle and incorporating more physical activity into their daily agenda.

So that we can decrease the number of obese children in America, we must recognize the impact of the disease on our children and the future of America. Only then, will we be motivated to change and able to encourage our children to change.

Literature Review

The Obesity Epidemic and United States Students

This article gives important and astronomical facts about the obesity epidemic in the United States. Among high school students, in 2009, after a Youth Risk Behavior Survey, the Centers for Disease Control and Prevention (CDC) was able to reveal several unhealthy dietary behaviors and a lack of physical activity. It was rather disturbing. The survey revealed that high school students, during the seven days before the survey, indulged in carbonated beverages and ate less fruits and vegetables. During the seven days before the survey, there was also a limited amount of 100% fruit juices drank and/or fruit eaten. Prior to the seven days before the survey, some of the high school students didn’t participate in, at least, sixty minutes of physical activity on any given day. Physical education classes were not attended either. The focus, it appeared, was more on watching television and utilizing computers.

The CDC offered, what would be assumed by most adults, reasonable solutions. It was suggested that the students be placed in healthier educational environments, receive better health education, and more physical activity programs. Along with what the CDC revealed about the survey, The School Health Policies and Programs Study in 2006 indicated that more students were able to purchase sodas or fruit drinks and less 100% fruit juices. However, nutrition services did offer more vegetables and gave the high school students the option to choose between different fruits. The choice was offered, in some schools, for students to participate in intramural activities or physical activity clubs. (The Obesity Epidemic and United States Students, 2010)

Obesity Prevalence among Low-Income, Preschool-Aged Children — United States, 1998–2008

This article reports the results of a study done regarding the presence of obesity and racial/ethnic disparities in pre-school aged children. The study looked closely at the racial/ethnic differences and early-life risk factors for childhood obesity.

During this study, “a total of 1343 white, 355 black, and 128 Hispanic mother-child pairs were studied” (Obesity Prevalence Among Low-Income, Preschool-Aged Children — United States, 1998–2008, 2009). The major findings were risk factors that started prenatally up to 4 years of age.

The results of the study revealed that black and Hispanic children displayed a number of risk factors related to childhood obesity. Some of those risk factors included increased rates of depression and rapid weight gain. It was also presumed that black and Hispanic mothers introduced solid foods to their infants prior to the appropriate months of age. As the children reached two years old, they were introduced to more sugar-sweetened beverages. Fast food appeared to be the first choice of foods.

In conclusion, the study did in fact; show significant differences in risk factors for obesity in black and Hispanic children. It was discovered the risk factors for obesity are present prenatally as well as throughout childhood.

Facts for Families

Obesity in Children and Teens

This article was very informative. It opens up with a shocking fact and number; “unhealthy weight gain due to poor diet and lack of exercise is responsible for over 300,000 deaths each year” (Obesity in Children and Teens, 2008) I discovered that obesity is more than just a pound or more of extra weight. Based on this article, obesity in children normally begins in early childhood ages. If the child continues to display no change in obesity before or during pre-teen years, then he or she is more than likely to become an obese adult.

The article gives several possible causes of obesity relating to instances such as; “lack of exercise, family and peer problems, low self esteem, depression or other emotional problems, and overeating or binging” (Obesity in Children and Teens, 2008). When dealing with obesity, if the parent(s) and children are not careful, there are a number of consequences including: trouble sleeping, mental, physical, and emotional.

The author explains how obesity can be managed and treated in children and adolescents. However, the author also expresses how it’s easy for the child and/or adolescent to gain the weight back. It is important that old habits of eating and exercising not resurface. The author states, “An obese adolescent must therefore learn to eat and enjoy healthy food in moderate amount and to exercise regularly to maintain the desired weight” (Obesity in Children and Teens, 2008).

Weighing the Risk Factors

The writer displayed a picture of a handsome toddler with obvious weight issues. The child appeared to be happy but after reading the article, I discovered that this child is at very high risk of remaining obese through his adolescence years and into adulthood. It is suggested that “efforts to prevent childhood obesity should begin far earlier than currently thought-perhaps even before birth” (Burton, 2010). Obesity is affecting more minority children than white children. Beginning at infancy and even pregnancy, studies were revealed and proved that minority children are at a higher risk for obesity.

The author points out that socioeconomic status may be a possible risk factor. There have been theories provided that state limited access to health care, poverty, and low educational levels are contributing factors for obesity in minority children.

The writers suggest, “The risk factors stem from behaviors and habits passed from generation to generation or that may be culturally embedded” (Burton, 2010)

The Role of Media in Childhood Obesity

This article summarizes findings from the Centers for Disease Control and Prevention and the American Academy of Pediatrics findings on the role of the media in childhood obesity.

Data reported from CDC dating back to 1980 indicates that the number of obese children ages “6-11” has increased by twice as much. This data also indicates that the number of adolescent youth has increased by 3 times as much (The Role of Media in Childhood Obesity, 2004)

The American Academy of Pediatrics states, “The increase on childhood obesity represents an unprecedented burden on children’s health.” (The Role of Media in Childhood Obesity, 2004)

This article also explains the importance of relevant policy recommendations for change. The following policy recommendations were listed: reduction in commercials for food that are aimed at children, increase education campaigns and encourage healthy eating and more exercise, incorporate more communications regarding healthy eating to television episodes, and encourage interventions that decrease the amount of time children access media,

The article states many contributing factors to the increased numbers of overweight children. The article lists these factors as, “reduction in physical education classes and after school athletic programs, an increase in the availability of sodas and snacks in public schools, the growth in the number of fast-food outlets across the country, the trend toward “super sizing” food portions, and the increasing number of highly processed high-calorie and high-fat grocery products.” (The Role of Media in Childhood Obesity, 2004). The article lists food advertisements as the number one factor that media contributes to childhood obesity. The article states that the number of TV commercials has increased by 2 times as much in the last 40 years.

New Data Analysis Shows Possible Link between Childhood Obesity and Allergies

This article expresses a new indicator that may reduce childhood obesity. A study published in an issue of the Journal of Allergy Clinical Immunology states , that “obese children and adolescents are at increased risk of having some kind of allergy, especially to a food” (New Data Analysis Shows Possible Link between Childhood Obesity and Allergies , 2009) It is said to be some sort of connection between asthma and allergies in obese children and adolescents.

This study was supported and led by the NEIS and NHANES. The researchers analyzed data from more than four- thousand children. They looked at and compared allergen-specific immunoglobulin E (IgE) or antibody levels to a large panel of indoor, outdoor and food allergens, body weight, and responses to a questionnaire about diagnoses of hay fever, eczema, and allergies. Obesity was defined as being in the 95th percentile of the body mass index for child’s age. The researchers found the IgE levels were higher among children who were obese or overweight. “Obese children were about 26 percent more likely to have allergies than children of normal weight” (New Data Analysis Shows Possible Link between Childhood Obesity and Allergies , 2009).

There are more studies expected to take place on this and there will continue to be a need to try and determine how environmental factors affect the epidemic of child and adolescent obesity.

Obesity Prevalence Among Low-Income, Preschool-Aged Children– United States, 1998-2008

This article gives details of the affects of low-income and minority obese children. There is data presented by the CDC’s Pediatric Nutrition Survelliance System (PedNSS). The CDC examined trends and discovered that “obesity prevalence among low-income, preschool-aged children increased steadily from 12.4% in 1998 to 14.5% in 2003, but subsequently remained essentially the same, with a 14.6% prevalence in 2008” (Obesity Prevalence Among Low-Income, Preschool-Aged Children — United States, 1998–2008, 2009). It is suggested that there should be strategic planning of an effective intervention that will focus on environments and policies that promote physical activity and a healthy diet for families, child care centers, and communities. There were several additional studies mentioned and all concluding the same necessary strategic planning to fight the epidemic of childhood obesity.

Overweight in Early Childhood Increases Chances for Obesity at Age 12

The article is conveying the same message about childhood obesity that many researchers focusing on this epidemic continue to convey. Children who are overweight as toddlers, infants, or preschoolers are more likely to be obese or overweight as an adolescence. However in this article, gives brief descriptions of recent analysis that focus more on frequent intervals of data collected on children from the age of two through the age of twelve years of age. This analysis was also done over an extended period of time.

The analysis revealed that overweight children in early childhood increases chances for obesity at age 12. (Overweight in Early Childhood Increases Chances for Obesity at Age 12, 2006)

Hypothesis

Topic: Is the rise in Childhood Obesity a result of a sedentary lifestyle or due to pre-disposing factors?

Research shows that rising number of obese children cannot be attributed solely to sedentary lifestyle or to predisposing factors. The research sites a number of factors that attribute to the childhood obesity epidemic. Careful examination of the lifestyle factors and predisposing factor for obesity of today’s youth is essential in finding a way to decrease these rates.

Policy Recommendations

The following recommendations may be helpful in addressing childhood obesity in the United States:

Policies addressing childhood obesity must take into consideration the many different factors that contribute to this epidemic. Policy makers must be aware of the predisposing factors that may contribute to the disease. It is imperative that parents who show risk factors of having obese children receive an intervention while the child is still young. Programs designed to deal with childhood obesity must look at the lifestyle of the child and the parent, genetic factors, and economic status. Healthy foods are often more expensive that unhealthy foods. We must find ways to make healthy foods available and affordable for our children. Careful consideration must be taken in dealing with children who may be obese due to genetic factors.

Policy makers must be aware of the affects of the media on obesity. There has to be some control placed on advertisement for unhealthy snacks and meals that are geared towards young children. The media should be encouraged to have more positive roles for characters that do not fit in the “ideal weight” category. The media can also use celebrities and musicians to positively promote healthy foods and a healthy lifestyle.

The most important recommendation is that policy makers are aware that proper planning and implementation of programs nation -wide will be needed to decrease the number s of children with obesity. This will take time. This will also take a joint effort from parents, churches, state and federal governments, and community advocates. We must make this a priority in order to insure the health of our nation in the future. Working citizens should be aware of the possible financial burden that this disease could end up being if we do not address it in the near future. Health care costs are rising on a daily basis. We must ensure that we are financially able to handle this epidemic in the future. If prevention programs are not put in place, today’s obese youth will be tomorrow’s obese adults. These obese adults of the future may possibly give birth to obese children. We must stop this endless cycle and control this epidemic for our children.

Various gastrointestinal and genitourinary etiologies may need the creation of urinary or fecal diversion. These may include inflammatory bowel disease, diverticular disease, intestinal obstruction, colon-rectal cancer, gynecological cancers and gastrointestinal trauma (Beitz, 2004). Indications for coming up with the urinary stoma include; neurogenic bladder, bladder cancer, refractory radiation cystitis and interstitial cystitis. The cause of the disease will determine if the condition will be a temporary or permanent one (Thomas and McGinnis 2004).

Among various types of surgically created ostomies, colostomy involves the opening made on the large intestine to allow for the passage of stool. The location of colostomy can be in sigmoid, transverse or ascending position. In this case, surgical resection will ultimately determine the stool output consistency. Ileostomy is a surgical construction from the small intestine and it is located high in the gastrointestinal route hence the stool output is comparatively of high quantity and liquid consistency (Gordon and Vasilevsky, 2004). Ileal conduit or urostomy is made using a short portion of the ileum to assist in urine elimination. Ureters are connected to conduit to allow urine to flow out of the body into ostomy pouch through the stoma (McGinnis and Tomaselli, 2004). Whether the ostomy is temporary or permanent, nurses must posses the knowledge to give the patient and the family the necessary information to improve recovery and enable a positive experience when obtaining information about ostomy care.

Patient education.

Any patient who is scheduled for an ostomy surgery can experience a number of feelings like fear, anxiety, depression and loss of body image especially if the cause of the surgery is a diagnosis related to cancer. Pre operative teachings assist the patient by receiving these feelings and contribute to quick recovery of the patient (O’shea, 2001). A very important ingredient in the teaching procedure before the operation is the Wound Ostomy and Continence Nurse (WOCN). Counseling before the operation allows for the assessment of the patient’s knowledge about the disease, support systems, level of education, employment, physical activity involvement, financial concerns and hobbies. Assessment of any physical shortcomings is also necessary because poor manual dexterity, poor vision and loss of hearing may affect the patient’s ability to undertake ostomy self care. Patient’s spiritual and cultural beliefs should be also assessed because certain particular rituals concerning ostomy care may need to be taken in. Employing all these factors can assist the patient to recover successfully and feel confident in managing the condition (O’shea, 2001).

WOCN reviews the cause of the disease, stoma characteristics, surgical procedure, peristomal skin care, dietary considerations and a variety of ostomy appliances. If appropriate teaching proceedings may enable the patient to have an insight of the ostomy pouching system. Use of teaching booklets and illustrations helps to improve the education.

Another component of preoperative teaching is the stoma site marking. This is recommended for all who are set to undergo a permanent or temporary stoma (Goldberg and Carmel, 2004). A poorly located stoma on the patient’s abdomen can lead to peristomal skin complications, stool and urine leakage, stoma, emotional and physical stress for the patient. During stoma site marking, there is abdomen assessment with the patient in sitting standing and lying positions. Also the abdomen can be assessed for the skin folds, bony, creases, scars and prominences. Patient’s belt and line should be avoided from the stoma site and not affect any prosthetic devices. The stoma site should also be put in an area that the patient can visualize and access. Ideal stoma site is situated in the anal muscle that extends to symphysis from the xyphoid process (Goldberg and Carmel, 2004).

Nursing education.

In stoma assessment the patient must enter the operating room with the pouching system on stoma. Immediately after the operation the, a transparent pouch is recommended to enable the nurse to have a view of stoma characteristics and stool and urine presence (Goldberg and Carmel, 2004). Initially after the operation period, the stoma can appear edematous, red, shiny and moist. In general terms, the stoma is red to pink in color according to tissue that was used in construction. Brown to dark color may show stoma ischemia and the consultations must be made with the physician.

The shape of the stoma ranges from round to oval. It changes its shape and size in a period of six to eight weeks after the surgery. Since the stoma decreases in size with time, the nurse must use a skin barrier that has been cut to fit to the stoma (Goldberg and Carmel, 2004). For the first six to eight weeks after the surgery, measurements of the stoma should be taken each time the barrier of the skin is changed. Measuring guides are provided to measure round stomas, oval stomas will need the length and width measurements of the stoma (Colwell, 2004). Lack of sphincter by the stoma to regulate the passage of urine or stool, then the opening should be placed near the center of the stoma to aid the flow of urine and stool (McCann, 2002).

The stoma may not or may protrude out of the skin surface. Stomal protrusion vary from a flush stoma at the skin level to a moderate one which is about 1-3 cm in length (Erwin-Toth and Doughty, 2002). Actually, stoma protrusion should be at least 0.8 inches above the skin level (Colwell, 2004). Protruding stoma helps urine and stool to flow into the pouch directly. A flush stoma is not suitable because it can cause difficulties when skin barrier attaches to it and leakage of stool below the skin barrier leading to peristomal skin irritations.

The stoma output is determined by the location of ostomy. The output resulting form the ascending colon produces a semi liquid consistency whereas the one from the transverse colon produces a semi-liquid to pasty consistency and the one located in a sigmoid or descending colon will be more of a solid stool (McCann, 2002).

An Ileostomy stool output is constant and watery with a lot of digestive salt and digestive enzymes. At the initial postoperative stages, the stool may be greenish and thick. The stool output from Ileostomy range from 800-1,700 cc in one day (Colwell 2004). When the patient comes back to the regular diet, there is development of the stool consistency from the ileum and a reduced out put in a daily basis ranging from 500-800cc/day. With time the small intestines recovers and with a decrease in stool output (McCann, 2002). Urine is immediately produced after the surgery by the Ileal conduit stomas. It is usually normal for the urine to be blood-tinged after the operation. Also the small intestines produce mucous which may be seen in urine (Colwell, 2003).

Peristomal skin care involves the protection of the peristomal from coming into contact with the urine and stool to stop the occurrence of peristomal skin complications. Skin barrier needs to be properly measured to suit the stoma. If the skin barrier opening is too large, urine or stool will cause irritation on the peristomal skin area. The opening should not be more than 2cm larger than the size of the stoma. Cleanliness of the peristomal skin can be done by gently using warm water then dry it. Moisturizing soaps must be avoided because they affect negatively the skin barrier attachment. Male patients need to be taught trimmed peristomal using electric razor, scissors and other safety devices in an outward manner from the stoma (McCann, 2002).

When choosing the pouching system of the patient, the information that was gathered before the operation is heavily relied upon. Other factors to be considered include location of the stoma, its size and shape plus the anatomical location. Pouching system should give anticipated wear time and protect the underlying skin from stool and urine (Colwell, 2003). Most of the pouching systems are designed in a way that the weight is light, easy to maintain and odor-proof (Colwell, Carmel and Goldberg, 2001).

One of the most important components of the pouching systems is the skin barrier because it protects the peristomal skin from stool and urine (Colwell, 2004). Skin barriers can be found in either cut-to fit or pre-cut product. The pre-cut models are meant for the round stomas. Barrier opening should fit stoma size to limit the probability of the urine and stool coming into contact with the peristomal skin. The cut-to fit models can be used in oval stomas or the ones which are irregular in shape. The cut-to fit barriers are the commonly recommended in initial postoperative stage because the size of the stoma will reduce for not less than six to eight weeks from the day the surgery was performed. A large skin barrier may cause peristomal skin problems resulting from the exposure to stool or urine (Colwell, 2004).

Skin barrier wear time is necessary; the barriers are either classified as extended or standard. The difference between the two lies in their interaction with the moisture and the degree of affinity to the skin. The two barriers absorb the moisture. However, the extended model absorbs moisture slowly as compared to the standard model. This delays the erosion of the skin barrier (Colwell, 2003).

Skin barriers have flat or convex shapes. At the back of a f lat barrier is one level surface while the convex one has an outward protrusion. Skin barriers are made with in-built convexity which is created by putting the ring into the barrier. The intention of the curve is to place pressure in a downward position to the peristomal skin to enable the stoma to protrude in an outward position (Colwell, 2003). Different convexity depths are referred to as deep, moderate and shallow. Generally convexity is used in stomas which are flat and retracted to minimize urine and stool leakage below the pouch. Also the convexity can be used in abdomens with skin folds or soft abdomens in peristomal skin (Colwell, 2004).

Various ostomy pouching systems are available. It is therefore necessary to elaborate to the patient that the systems used in hospital after surgery may not be necessarily the system he or she will continue using after recovering from the operation. The following must be considered while selecting the ostomy pouching system; the ostoma size and shape, effluent type, presence or absence of abdominal folds and contours and the type of the ostomy. The patient’s manual and visual dexterity must be considered as well including day to day activities (Colwell, 2004).

Pouches sealed to the barrier are categorized as a single piece, and systems that are connected to the skin barrier are seen as a double piece. A two piece pouch gives the patient the capacity to change or remove it without altering the skin barriers. Again it is easier to position the skin barrier at the middle of the stoma. One mechanism for making sure that a two piece pouch is closed is will ultimately depend on the ability of the patient to snap the pouch and the wafer together. Application of the pouch to the wafer will require the patient to be instructed so that he or she can listen to an audible click to make sure that the pouch is safe to the skin barrier.