The essay is based on a patient who had surgery to have an ileostomy formed. This essay will attempt to define support and identify what the patient’s specific support needs may be within the context of the patient’s post-operative psychological adjustment to her new stoma with special focus on the issue of flatus and odour on the patient’s recovery. Black (2001) states that for the patient with a newly formed stoma, thoughts of talking to others, eating, working, sleeping or making love while bowel motion and flatus fill the appliance is horrific. A literature review will identify the most recommended suggestions for support of the person anxious about odour and flatus and the information will be considered within the context of the support that was given to Jane*.
In accordance with the Nursing & Midwifery Council Code of Professional Conduct (2008), the name and any identifying details of my patient on which this study is based will be withheld.
Jane* is a 44 years old mother of three, including 16 years old Adam* who lives with her at home. Jane is in a long term relationship with Peter* and they have been planning to move in together. She is a teacher of Economics in the local secondary school. Jane was diagnosed with Ulcerative colitis about 18 years ago.
Ulcerative colitis is a disease that causes inflammation of the large intestine or colon (Colitis UK, 2008). This is the last meter or so of the intestine closest to the anus. Symptoms are vary in severity from pain and discomfort, through mucous in the stools is in the most severe cases blood in the stools. It is generally diagnosed by inspection of the colon by the procedure colonoscopy by uses an endoscope.
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Porrett and McGrath (2005) suggest, ileostomies are formed to treat conditions such as inflammatory bowel disease, diverticular disease, carcinoma of the bladder, carcinoma of the bowel, traumatic injury to the abdominal area, and inadequate blood flow to the bowel, incontinence and obstruction. An ileostomy is a surgically created abdominal opening from the terminal small intestine (ileum), made because the entire colon has been removed or must be bypassed. An ileostomy stoma is usually on the lower-right abdomen. Its output has passed through all or most of the small intestine, but none of the large intestine; consistency of this output may vary from very liquid to a semi-solid paste (Porrett and McGrath, 2005).
Simmons K et al (2007) state that more than 13,000 patients have stoma surgery yearly in the United Kingdom and reports psychological and social dysfunction in patients whose surgery end with stoma. Patients undergoing stoma surgery face a number of stress related circumstances leading to threats to body integrity, alerted body image, loss of autonomy, and loss of function and control (Williams, 2005). Annells (2006), suggests that fear of rejection by friends and family as well as being ostracized by society is constant for this group of patients and that support, guidance and information can assist them in adapting to their new way of life. Patients were reported to have feelings of loneliness, low self-esteem, thoughts of suicide and depression are higher in stoma patients compared with patients without a stoma (Norton, 2004).
Patients who have had ileostomies, often have a distorted body image which has a knock on impact on the patients’ physical integrity and self-concept (Black and Hyde, 2004).
When I was talking to Jane, before and after surgery, one of her major anxieties was flatus and odour – common concern for those with a new established stoma is flatus and odour which can result in psychological distress, stigma and embarrassment (Annells, 2006). She was also anxious about how Peter would react to the stoma and whether he would still find her beautiful and attractive. But mostly, she was concerned that people would smell her and she was worried, that she would be unable to control her flatus and being stigmatized by Peter and people who found out that she had stoma. Coping with stigma involves a variety of strategies, and Jane was at the stage where she was deciding whether to disclose the condition and suffer further stigma or attempt to conceal the condition or aspects of the condition and pass for normal (Joachim and Acorn, 2000), but felt certain that there was no way she could conceal the odour or the involuntary flatus. Flatus and odour that cannot be controlled by the individual for medical reasons affect how these individuals feel about their bodies (Black, 2001). A stoma does not have a sphincter muscle; and so persons with stomas are unable to control the elimination of faeces or flatus via the stoma (Breckman, 2005). Rozmovits and Ziebland (2004), in a compilation of narratives from new stoma patients cited many as expressing difficulties in returning to work following surgery due to the “uncontrollable and unpredictable bowel movements and foul-smelling gas”.
Simmons K et al (2007) state social aspect has a major impact on patients. A background study reported a decrease in social and leisure activities, increase in marital problems and less contact with relatives and friends.
Mosby (2006), defines support as “to sustain, hold up, or maintain in a desired position or condition, as in physically supporting the abdominal muscles with a binder or emotionally supporting a client under stress”. There are several definitions for support. The Cambridge Advanced, Learner’s Dictionary (2008), define support as “to encourage someone because you want them to succeed”, “to help someone emotionally or practically”, or “a group of people who provide emotional and practical help to someone in serious difficulty”.
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Gale (2001) tells us social support consist of friends, family members, co-workers who provide assistance to the individual in need. Support found from friends, family and co-workers has a beneficial effect on physical and psychological well-being. Jane has had counselling from the stoma care nurse and assessed before surgery. Jane’s partner, Peter was not included initially in her pre-operative period as she did not wish to have him there. Peter was aware about the operation but she had not told many of her family and friends. Myers (1996) state psychological preparation and counselling of patients in the pre-operative period is of great importance. Myers (1996) further states the stoma nurse together with the patient’s partners and other health professionals help to rehabilitate the patient. The nurse and healthcare professionals must look at the patient and the patient’s needs holistically to include all aspects: physical, emotional, mental, social and economical.
Faulkner and Davies (2005) state, that there is a range of definitions of the concept of support. It implies it is the exchange of resources between at least two people, intending to enhance the well-being of the person receiving. Faulkner and Davies (2005) illustrate the four broad support mechanisms they are emotional, informational, appraisal and instrumental support. Emotional support is about improving self-esteem, encouraging the person and aiming to have a feeling of belonging, accepted, loved and needed. Informational support provides information for individuals which enables them to be involved in dealing with their problems and problem solving. It can involve suggestions of where they can acquire further advice. Instrumental support involves tangible resources to remove, or significantly reduce, the stressful situation experienced by an individual. This also may include the provision of financial aid or services. Appraisal support helps the person to evaluate the impact of their circumstance, and level the threat posed by the stressful event or availability of personal coping resources.
Post-operatively, Jane required all the identified types of support in dealing with her anxiety about her flatus and odour. Sirota (2006) states that support is important at all levels of care of the stoma patient and is especially critical in the early postoperative stages following stoma surgery when patients are experiencing grief reactions to loss. Emotionally, the support had already begun with the pre-operative chats that involved not only Jane, but her partner, Peter as well. The nurse, in offering support to the patient following a stoma formation must be conscious of the fact that even though the patient is extremely self-conscious about odours related to the newly-formed stoma, odours from the stoma should never be smelled by anyone but the patient (Williams, 2005). Emotional support to Jane was provided by developing a rapport with her which helped to alleviate her anxiety and embarrassment by putting the issue of flatulence and odour into context and teaching the patient techniques that could help control the issues e.g. deodorants, diets (Williams, 2005).
Informational support was given to Jane about the types of food that will reduce odours and flatulence. Information such as which foods and fluids will produce flatus and which are likely to cause odour; how to manage a noticeable bulge created by flatus and how to remove flatus from appliance without causing unnecessary embarrassment in terms of odour or spillage are crucial to developing the patient’s confidence in managing his/her stoma (Breckman, 2005). In addition, leaflets obtained from the Ileostomy & Internal Pouch Support Group gave a list of foods that increase and decrease flatulence and faecal odour as well as hints on reducing flatus.
Instrumental support for Jane took the form of the deodorants that were provided to her to deal with the odours from her stoma. Cottam and Porrett (2005) recommend that in instances where odour is a problem, such as when changing the appliance, deodorants can be used to mask faecal odours and these are available in atomizers, drops or powders that can be sprayed into the atmosphere or placed inside the appliance. Jane was given the opportunity to try different samples of different fragrances by the stoma care nurse and then advised how she could order them in the future. She was also able to examine the different costs so that she could order deodorants that suited her budgets. She also advised to use the silicon-based adhesive remover which was proven to be gentler on the skin (Cutting, 2006).
The final aspect of support that was provided to Jane in alleviating her anxiety about flatus and odour was appraisal support. Any disruption to the workings of the person’s body is bound to cause concern and in Western society the pressures placed on us by media and peers mean that the patient that has to live with a stoma has to live with a stigma and all the anxieties associated with this (Williams, 2005). With the informational, emotional and instrumental support that was given to Jane, the rest of support needed by her can only be identified and accessed by her. Support groups and their contact details were provided to Jane, so that she can access a group or forum, if she determined that she needed further support of more specific, or even generic, type. The success of Jane’s adjustment will now be dependent on her own coping strategies and her own support networks (Williams, 2005).
Salter (1997) stated that the support a nurse needs to give the patient with newly formed stoma is emotional, informational and practical. Jane received all of the above during her immediate post-operative period. Price (1993) says that how Jane copes now will be affected by the opinions and attitudes of the people with whom she has close relationships. Informational and appraisal support will continue via support group and forums and emotional support will come from family and friends. In the end, Jane will increase her self-confidence and become more independent with dealing with her stoma and stoma care. But in the end, as with everyone, even those without a stoma, support of all kinds will always be needed in some degree, form or fashion.
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