Coping with an ileostomy

Dietary management for people with an ileostomy: a scoping review

OBJECTIVE

The objective of this review was to identify and map the evidence for oral dietary management of ileostomies.

INTRODUCTION

Dietary advice is commonly provided for ileostomy management but can be inconsistent, conflicting, and inadequate. There is a lack of high-quality research investigating dietary management of ileostomies. This scoping review highlights gaps in the literature that need addressing to inform practice, and identifies dietary strategies and outcomes to be investigated in future studies.

INCLUSION CRITERIA

Evidence relating to the use of oral dietary strategies to manage complications and nutritional consequences associated with having an ileostomy was included. Evidence included all types of original research (ie, quantitative and qualitative methodologies, expert opinion articles, and consensus guidelines).

METHODS

This review followed JBI methodology for scoping reviews. A pre-determined search of 13 databases, including MEDLINE, Embase, and Web of Science, was conducted in August 2019. The search was not limited by date, but during screening, expert opinion evidence was limited to 2008 onward. Data extraction was carried out by two reviewers for each study/article using a database tool designed specifically for this review. Results are presented using a combination of tabular summaries and narrative reports.

RESULTS

Thirty-one research studies were included: 11 experimental (including four crossover randomized controlled trials), three pre-post design, 13 observational (12 cross-sectional, one longitudinal), and four qualitative. Forty-four expert opinion articles/guidelines were also included. In experimental studies, nine nutrient modifications and 34 individual foods/drinks were investigated. In pre-post studies, 10 nutrient modifications, 80 foods/drinks, and 11 eating-related behaviors were investigated. In observational studies, eight nutrient modifications, 94 foods/drinks, and five eating-related behaviors were reported. In qualitative studies, two nutrient modifications, 17 foods/drinks, and one eating-related behavior were reported. In expert opinion articles/guidelines, recommendations relating to 51 nutrient modifications, 339 foods/drinks, and 23 eating-related behaviors were reported. Although large numbers of individual foods and drinks were suggested to be associated with outcomes relating to ileostomy management, findings from observational studies showed these were generally reported by <50% of people with an ileostomy. The most common nutrients reported in association with outcomes related to ileostomy management were fiber, fat, and alcohol. Across most outcomes and studies/expert opinion, low fiber and low fat were suggested to be beneficial, while alcohol was detrimental. Other nutrient associations frequently reported in expert opinion (but with minimal attention in research studies) included negative consequences of caffeinated drinks and positive effects of white starchy carbohydrates on stoma output. Output volume and consistency were the most commonly reported outcomes relating to ileostomy management across all study types. Flatulence and odor were also common outcomes in observational studies.

CONCLUSIONS

This review found an abundance of literature, particularly expert opinion, reporting on dietary management for people with an ileostomy. However, this literature was highly heterogeneous in terms of dietary strategies and outcomes reported. It is likely that most dietary advice provided in practice is based on expert opinion with some supported by limited research. High-quality research investigating the effect of the dietary strategies identified in this review on commonly associated outcomes relating to ileostomy management is needed to improve evidence-based advice.

Prisons and Embodiment: Self-Management Strategies of an Incarcerated Population

Weight gain and obesity in prison are, like elsewhere, associated with an increase in caloric intake and reduction in physical activity, but these factors are not solely under the control of a prisoner. Nineteen semistructured interviews were conducted in two male prisons in the United Kingdom to explore participants' thoughts, beliefs, and feelings on the role prison plays on weight change. Data from interviews were analyzed through grounded theory methodology. The concept of embodiment was used to explain not only how prisoners tend to believe the physical and emotional consequences of imprisonment could adversely affect weight and health but also how they adapted behaviors toward their health to try to take back control and power over their lives. The changes in prisoners' health-related behavior due to imprisonment show similarities to those seen in individuals responding to chronic illnesses, which suggest that imprisonment might be viewed as akin to an illness of the body.

Cancer Survivorship at the Intersections of Care and Personhood

Surviving colorectal cancer following ostomy surgery with an intestinal stoma presents numerous challenges to the cultural category of full adult personhood. The foremost is managing unpredictable bowel activity. The technical management of the ostomy facilitated by biomedical specialists, is essential for personhood realignment. This article focuses on how some female long-term cancer survivors manage and adapt to this new fecal habitus by mobilizing various assemblages of care - receiving care, continuing to provide particular gendered forms of care, and returning to caregiving roles. These interdependent practices of care realign personhood, or at the very least, minimize the assaults that having an ostomy presents to the cultural category of full adult personhood.

Adjusting to bodily change following stoma formation: a phenomenological study

PURPOSE

Scant research has been undertaken to explore in-depth the meaning of bodily change for individuals following stoma formation. The aim of this study was to understand the experience of living with a new stoma, with a focus on bodily change.

METHOD

The study adopted a longitudinal phenomenological approach. Purposeful sampling was used to recruit 12 participants who had undergone faecal stoma-forming surgery. In-depth, unstructured interviews were conducted at 3, 9 and 15 months following surgery. A five-stage framework facilitated iterative data analysis.

RESULTS

Stoma formation altered the taken-for-granted relationship individuals had with their bodies in terms of appearance, function and sensation, undermining the unity between body and self. Increasing familiarity with and perceived control over their stoma over time diminished awareness of their changed body, facilitating adaptation and self-acceptance.

CONCLUSIONS

Stoma formation can undermine an individual's sense of embodied self. A concept of embodiment is proposed to enable the experience of living with a new stoma to be understood as part of a wider process of re-establishing a unity between body, self and world. In defining a framework of care, individuals with a new stoma can be assisted to adapt to and accept a changed sense of embodied self. Implications for Rehabilitation Awareness and understanding of the diverse ways in which stoma formation disrupts the unconscious relationship between body and self can help clinicians to provide responsive, person-centred care. Supporting strategies that facilitate bodily mastery following stoma formation will facilitate rehabilitation and promote adjustment and self-acceptance. A concept of embodiment can help clinicians to deepen their understanding of the experiences of people living with a new stoma and the support they may require during the rehabilitation process. This paper provides clinicians with actionable insight that allows them to better support patients to a smoother adjustment process after stoma formation.

Complex and dynamic times of being chronically ill: Beyond disease trajectories of patients with ulcerative colitis

This article contributes to health research literature by problematizing the linear, sequential and intelligible understanding of time in the studies of illness. Drawing on the work of Martin Heidegger, it attempts to overcome the problem of considering the time of illness as either a framework controlling patients' experiences or a mind-dependent feature of their lives. The paper offers a conceptual analysis of the stories of ulcerative colitis patients from a recent clinical trial to present temporalities of illness as both objective and subjective, relational and dynamic. We attend to a combination of temporalities related to the ambiguous unfolding of illness and patients' relationships with such an unpredictable world of changing bodies, medical practices and temporal norms. Furthermore, our analysis reveals openness of times and considers ulcerative colitis patients as constantly evolving beings, with multiple possibilities brought about by illness. The paper highlights co-existence of times and considers patients' lives as incorporating a multiplicity of futures, presents and pasts. It concludes with conceptual observations about the consequences of developing complex approaches to illness in health research, which can better highlight the situatedness of patients and their multi-dimensional temporal foundations.

"I didn't feel like I was a person anymore": realigning full adult personhood after ostomy surgery

Colorectal cancer (CRC) is the third most common cancer in the United States. For some CRC patients, cancer treatment involves creating a permanent or temporary intestinal ostomy. Having an ostomy often results in complex social and physical concerns-including unpredictable and at times publicly noticeable bowel output. In this article, we discuss findings from 30 in-depth interviews with female CRC survivors with ostomies in the western United States. We highlight how having an ostomy disrupts culturally sanctioned practices of continence that mark the attainment of full-adult personhood. We discuss how survivors reclaim a sense of full personhood after ostomy surgery through a process of realignment that entails both learning how to manage ostomy equipment to conceal bowel activity and reappraising their illness and suffering. We suggest that the anthropological categories of personhood and personhood realignment be incorporated into research and interventions aimed at increasing support among cancer survivors living with bodily impairments.

Experiences of intimacy among people with bladder exstrophy

Previous research investigating the psychosocial and psychosexual impact of living with the complex genitourinary condition bladder exstrophy has been limited in scope and methodological quality. However, the limited evidence suggests that people with bladder exstrophy commonly encounter difficulties that might negatively impact their experiences of intimacy. We conducted an interpretative phenomenological analysis to explore intimacy in 6 participants aged 16 to 56 years. Participants discussed how their parents and later they themselves concealed their health condition. This concealment was associated with feeling safe and protected, yet shameful. Participants also discussed developing intimate knowledge of their own emerging identity while developing intimacy with others, as well as the importance of sharing the experience of bladder exstrophy with others in the development of intimate relationships. We discuss the findings in relation to theoretical issues of concealment, shame, attachment, psychosocial development, intimacy, and chronic illness.

Young people learning to live with inflammatory bowel disease: working with an "unclosed" diary

In a longitudinal study we investigated how young people come to live with a chronic disease, and asked them to record an audio diary on a regular basis. We also interviewed each participant every 6 weeks. Our analysis focused within and across the diary sets of 6 young people diagnosed with inflammatory bowel disease. All were aged between 11 and 16 years, and their recordings provided an insight into the experience of living within and beyond disease, and of negotiating health in the context of adolescence. This data collection method, which became known as the unclosed diary, was well received by the young people, who made use of their diaries in different ways. Three key aspects of their diary use, immediacy and intimacy, conversation, and reflection, demonstrate the flexibility of the method both as a means of accessing young people's lives at a time of change and development, and as a personal resource for the participants.

Difficulties Experienced by the Ostomate After Hospital Discharge

PURPOSE

This descriptive study used a mailed survey to identify difficulties related to the stoma that ostomates experience after discharge from the hospital, who they sought help from, and if the advice was perceived as helpful.

SUBJECTS AND SETTING

Ostomates who are 18 years or older and have undergone a urinary or fecal diversion at a North Carolina hospital between January 1, 2003 and June 30, 2005, were asked to respond to a survey about the difficulties related to their ostomy.

INSTRUMENT

The survey gathered demographic and anthropometric data, information regarding stomal complications, self-evaluation of emotional state, and contact with clinicians and support groups.

RESULTS

Of the 140 surveys mailed, 43 were returned, demonstrating a return rate of 31%. Thirty-four returned surveys were useable for statistical analysis. The top 5 difficulties experienced by the respondents were peristomal skin irritation (76%), pouch leakage (62%), odor (59%), reduction in previously enjoyed activities (54%), and depression/anxiety (53%). Twenty percent of the ostomates who experienced difficulties after surgery did not seek help. Ostomates primarily sought help from nurses when they experienced problems related to the stoma and its maintenance. For mental health, sleep, and sexual problems, a medical doctor was the practitioner of choice. Ostomates were satisfied with most of the help they received from an ostomy nurse; satisfaction was lower for home health nurses and surgeon or primary care physician practices. Average wear time for a stoma pouch was 4 days.

CONCLUSION

The majority of the ostomates experienced difficulty with pouch leakage, skin irritation, odor, depression or anxiety, and uneven pouching surfaces. Ostomates desire assistance with these problems and will benefit from long-term follow-up by an ostomy nurse.

Self-managing and managing self: practical and moral dilemmas in accounts of living with chronic illness

BACKGROUND

Patient education self-management programmes draw on sociological understanding of experiencing single chronic illnesses, but health practitioners do not always recognize the tensions and ambiguities permeating individuals' management experiences, particularly for those with multiple morbidity. The aim of this study was to illuminate how people negotiate multiple chronic illness, and everyday life.

METHODS

A sample of 23 people in their early 50s was recruited from a community health survey in Scotland. The participants had four or more chronic illnesses and were interviewed twice. The qualitative data that were generated highlighted the impact of illness and associated management strategies, as people attempted to continue familiar lives. Analysis was based on constant comparison and informed by a narrative approach.

RESULTS

People used multiple techniques to manage symptoms and conveyed a moral obligation to manage 'well'. However, maintaining valued social roles, coherent identities and a 'normal life' were prioritized, sometimes over symptom containment. This led to tensions, and participants faced moral dilemmas as they self-managed.

DISCUSSION

Self-management policies, programmes and healthcare practitioners need to recognize the tensions that people experience as they negotiate symptoms, valued social roles, positive identities, and daily life. Addressing these issues may improve opportunities to support patients in particular contexts, and enhance self-management.

Psychological considerations in gastrointestinal nursing

Body image changes and psychological adaptation are often associated with patients who have gastrointestinal disease due to the potential alteration to physical appearance through the very nature of the disease process or treatment. This article describes some of the psychological issues highlighted by patients with gastrointestinal disease, including loss of bowel control, withdrawal and concealment. It highlights altered image difficulties and adaptation through the patients' journey and treatment with illustrations from patients' narratives. In doing so, it explores the nurse's role and stresses the necessity for nurses to seek training to become skillful in counselling this group of patients towards exploring and identifying their individual psychological problems.

Expressions of loss of adulthood in the narratives of people with colorectal cancer

The diagnosis and treatment of colorectal cancer entail detailed discussions of bodily functions, invasive procedures, and a reorientation of life around bowel habit. Furthermore, people with stomas undergo a second experience of toilet training in adulthood. For these reasons, colorectal cancer is sometimes considered an embarrassing disease. Narrative interviews with colorectal cancer patients indicate the inadequacy of the concept of embarrassment in describing the loss of dignity, privacy, independence, and sexual confidence as well as a compromised ability to work, travel, and socialize. The link between bowel control and the constitution of adult identity must be acknowledged if health professionals and carers are to offer the most appropriate forms of information and support to people affected by colorectal cancer.

Encountering the downward phase: biographical work in people with multiple sclerosis living at home

This qualitative study examines how individuals in an advanced stage of multiple sclerosis (MS) who live at home, accommodate to their illness. The downward phase in the illness trajectory of MS often consists of a lengthy period of gradual decline. According to Corbin and Strauss's framework, accommodation is conceptualized as biographical work that refers to the actions taken to retain control over the life course and to give life meaning again. For our purpose semi-structured interviews with 22 people with MS were conducted and compared with 21 interviews with their family caregivers. The analysis consisted of fragmenting and connecting the data and involved close reading and constant comparison. The continuity of biography is at risk since body and performance failures lead to the loss of salient aspects of self. Participants interpret MS as an all-encompassing illness and emphasize the process of having to give up everything. Four case stories are described to demonstrate the complex intertwining of the biographical processes and to show the range in biographical accommodation. Some patients are capable of putting their lives back together again, while others retreat or do not consider MS a part of their lives. The unpredictable course of MS makes it impossible to give new direction to the life course.

Psychosocial issues: pelvic exenterative surgery

This review of the literature describes the psychosocial consequences of all the elements associated with Pelvis Exenterative Surgery (PES): a diagnosis of cancer and/or its recurrence, impact of procedures such as simple or radical hysterectomy, prostatectomy, or colostomy. All studies report a high incidence of anxiety, depression, self-image insult, sexual dysfunction, social isolation, and dysfunction. There are few studies of the consequences of PES itself. Their consensus is that its psychosocial impact is not as catastrophic as one would expect. However, their methodological drawbacks do not yet permit a definitive conclusion. The interaction of the patients with their surgeon and treatment team during the preoperative period is examined with special attention to potential pitfalls. Acute psychiatric syndromes that may occur during the postoperative period (delirium, anxiety, depression, brief reactive psychosis) and their management is discussed. So are sexual dysfunctions. General principles of intervention in preparing patients for invasive procedures and facilitating favorable outcomes are described. J. Surg. Oncol. 2001;76:224-236.

Stoma care: empowering patients through teaching practical skills

Teaching patients practical skills in stoma care is a complex process and although, arguably, at the very heart of stoma care nursing practice, has been largely ignored in the literature. Teaching principles are based upon social learning theory and educationalists provide guidelines on the most effective way to teach a practical skill. These guidelines have been utilized by nurses when teaching patients with newly formed stomas how to change a pouch. The process of adapting to a stoma and its daily management takes time. Psychologically, however, some patients will adapt more easily than others and researchers have attempted to identify factors which may account for this. Studies have demonstrated that patients who are satisfied with the amount of preoperative information they receive are less likely to develop psychological problems. Psychological adjustment may be affected if patients feel that they have developed insufficient pouch changing skills or have problems with leakage from their pouch or sore skin around their stoma. Studies have also demonstrated that cognitive factors, such as patients feeling in control of their illness and stoma, have been found to play a role in psychological adaptation. Clinical nurse specialists in stoma care are in an ideal position to target these cognitive factors using a variety of strategies including effective practical teaching to empower patients, thus facilitating psychological adaptation following stoma surgery.

Social and practical strategies described by people living at home with stroke

People with stroke are often referred to in negative terms. The phrase 'stroke victim' suggests that they are regarded as passive and deserving of pity, whilst 'the burden of care' implicates them negatively as an encumbrance to others. Much of the literature focuses on how stroke devastates peoples' lives, again casting the person with the stroke as an inactive victim of the illness, and subsequently a passive recipient of care. Against this background we aimed to find out whether people with stroke and their families take positive actions in response to the condition, and if so, to explore the nature of these actions. In-depth interviews were conducted with a consecutive sample of 40 people admitted to hospital in the East End of London, 10 months after their stroke. People with stroke were found to play an active and creative role in managing the aftermath of their illness. They (i) mobilized informal social support; (ii) created new ways of doing things; (iii) took things more slowly; (iv) began the process of relearning; (v) exercized; and (vi) 'covered up'. Families were found to be a major resource. These findings challenge the view of people with stroke as 'victims', who bring about a 'burden of care', and suggest that the majority of work after stroke is conducted not by clinicians or by formal carers, but by the person with the stroke and their families, at home. This needs to be recognized and respected by formal carers, who should base their interventions around the systems and routines established by families.

Sexual health issues in inflammatory bowel disease

Alterations in sexual health caused by inflammatory bowel disease (IBD) may affect quality of life and disease status. IBD usually strikes adolescents or young adults, who are also facing developmental milestones important to sexual health. Issues include growth and development, body image, intimacy and sexual functioning, fertility, and pregnancy. A review of published research regarding these issues, in addition to suggestions for nursing assessment and interventions, is included in this article. Nurses must offer sensitive support and suggestions for coping. Nurses must be aware of the issues influencing sexual health when providing total care to clients with IBD.

The body image in health and disease: exploring patients' maps of body and self

Patient education in chronic diseases should always take into account the many maps--individual, cultural and medical--that patients have of their own bodies, in both health and disease. Physicians should become explorers, working in co-operation with patients and their families to understand their perceptions of body and self--and whether or not these are compatible with medical interventions.

Body image in chronic illness--a reconceptualization

OBJECTIVE

Was to construct a classification system of the body image specifically relevant to patient experience of chronic physical disorder.

METHOD

To review both previous writings on body image and also data on psychosocial factors relevant to a variety of chronic illnesses. From this were derived four component parts of body image: comfort, competence, appearance and predictability. These are discussed in general and disease-specific terms.

RESULTS

Using this format, a classification system is offered. This is intended to be simple enough for routine clinical use and yet to offer some insight into body experience. An example is given.

CONCLUSION

Separating out the aspects of body image relevant to physical illness provides a clinically useful classification system. Further work is needed to determine its applicability as a research tool.

A behavioural modelling approach to curriculum development and evaluation of health promotion for nurses

This paper outlines the way in which two behavioural science models may be used in the processes of curriculum development and course evaluation. The models are the stress-coping paradigm associated with the work of Lazarus and the theory of self and identity developed from the work of Mead. It is suggested that a clear articulation of the underlying behavioural processes is fundamental in course design and appraisal.