Teaching the Adult Stoma Patient

Teaching stoma care to the new patient entails an assessment of the patient's readiness to learn and his or her cognitive and psychomotor abilities to understand strategies for appliance changing. The life-changing effect of stoma formation, whether the stoma is to be temporary or permanent, leaves the patient facing an altered body image and self-concept. The patient must learn new ways of caring for him- or herself that are different from the expected 'norm'. Good basic teaching principles combined with encouragement to empower the patient towards self-care will ensure that there is effective incorporation of the cognitive and psychomotor skills needed to manage a new way of life.

The patient's expectations of the teacher, in this instance the nurse, will be that they are knowledgeable, competent and able to provide the care and information needed along the path of recovery. The nurse, for her part, will expect the patient to be willing to learn and that the patient can make the necessary changes to his or her personal care and lifestyle (O'Shea, 2001).

Redman (1988) describes three components to learning: psychomotor, cognitive and affective learning. Although cognitive learning is equated with being literate, in patients who are unable to read and write through lack of education, as opposed to disability, cognitive learning can still be achieved. When teaching a patient, the nurse should use the language with which the patient is familiar, pausing frequently to ensure that the patient is not being confused by medical jargon. Once the patient has understood the essential information related to care of the stoma, he or she is able to move towards self-care.

Understanding a patient's attitudes and values, their affective learning, often starts when the patient first sees the stoma and the response to this stage may define how he or she will behave in the care of the stoma. Attitudes to the physical change in the body and change in the body image picture play a large part in the affective learning of the care of the stoma. The patient has to cope not only with his or her own body change, but also with the attitudes of partner, children, family, relatives, friends and work colleagues. The strong prohibitions on the uncontrolled passage of faeces and urine in western societies, as suggested by Littlewood and Holden (1991), may be a result of the value placed on a post-Cartesian self compared with the socially contextual and reverential notion of the self in non-literate societies. Dirt has been defined as matter out of place, and this implies that there is a set of ordered relations and a contravention of that order. The underlying feeling is that a system of cultural values habitually expressed in a certain arrangement has been violated. Often, individuals who undergo stoma surgery feel stigmatized, a term used by the Greeks to refer to bodily signs indicating something unusual about the person and used in modern medicine to refer to bodily signs of physical disorder (Black, 2000). Overcoming negative feelings about the stoma takes far more time in the new patient and accounts for cognitive learning being quicker than affective learning.

For the patient with a new stoma, learning to care for him- or herself requires a new skill of psychomotor learning. For many new stoma patients this area of learning is accomplished quickly between a few days after surgery and before the patient leaves hospital. The patient often has a fear of what he or she may see when the appliance is removed and this anxiety can be alleviated when the patient has an awareness of what appliance changing entails. The first stage is to understand what equipment is necessary for the patient to form the necessary mental picture of what he or she is going to be doing. The second stage is to understand that the patient is ready by the patient going to the bathroom with the required equipment for an appliance change. Third, the patient undertakes a guided response in changing the appliance, being allowed to take their time in an undisturbed atmosphere. The fourth stage enables the patient to change the appliance while being quietly supervised and, finally, the fifth stage empowers the patient to reach full self-care and go the bathroom as and when necessary to change his or her appliance and to transfer learning from hospital to home; this shows the essential knowledge that is required for successful appliance changing. The first box shows the knowledge needed for successful appliance changing.

In teaching the process of self-care to the stoma patient, the nurse must use assessment, diagnosis, planning, implementation and evaluation, and understand the patient's needs and expectations. During the patient's stay in hospital, he or she has had to take on a lot of new and confusing information about the disease that has caused surgery and a stoma to be raised. Often, in the case of diverticulitis, surgery has been done as an emergency, no preoperative preparation has taken place and the next thing that the patient knows is that he or she has woken up with a stoma. Often the patient can feel so overwhelmed by what has happened in the last hours that his or her attention wanes when different members of the multidisciplinary team all approach at different times with information. It also has to be remembered that patients learn in different ways and use many strategies to cope with learning new ways of caring for themselves with a stoma, and attention span and motivation will occur in periodic plateaux. All of these strategies of learning will help the nurse to understand that stoma instruction cannot be completed in one lesson.

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