As the number of elderly requiring ostomies continues to rise, the goal of returning them to their homes or long-term care facilities with their independence and self-esteem intact becomes increasingly important. Yet, reaching this goal is often difficult. One reason is that today the elderly person, like other patients undergoing an ostomy procedure, is usually discharged within 5 to 6 days after the operation. At this early stage, their ostomy may have just begun to function and they are still experiencing the shock and disbelief accompanying this event. Another roadblock to reaching the goal is that the older patient is often already coping with several existing problems. Fortunately, there are some specific strategies that can be very helpful.
Take a few minutes to identify your elderly patient's strengths. This will emphasize the positive for both you and your patient. This is important because each of your elderly patients will probably have many challenges, such as chronic illness, sensory deficits, and feelings of depression after the ostomy. Therefore, it is easy to focus on these problems and not realize that these patients also have many strengths. We have found that the best way to discover these is by encouraging them to reminisce. As you listen you will learn about abilities on which to focus when devising your teaching plan.
For example, by using this technique with one elderly woman, we discovered that despite the fact that she graduated from high school during the depression, she worked to finance her entire college education. She had been a teacher for many years and, after her retirement and the death of her husband 20 years ago, she had maintained her own home. She also told us that even though her hands were very "arthritic," she had managed to knit and play the piano. Therefore, after talking with her for a very short time, we identified her strengths as a fighting spirit; a sense of humor; the ability to learn; and the capacity to laugh at herself.
The self-esteem of the elderly person with an ostomy is acutely threatened, but several strategies can help restore it. Remember to make a conscious effort not to reveal any negative feelings about the ostomy that you may have. Your facial expressions and nonverbal cues will be closely watched when you are performing any of the ostomy care. Most often it is your face, not your hands, that are observed by patients when they receive lessons in colostomy care. Remember, also, that when you include family members or friends in the teaching, it is important to warn them of this as well. The experience of a negative reaction from another individual can lead to fear of being repulsive to others and ultimately, to avoidance of social functions.
TIPS FOR TEACHING THE ELDERLY PATIENT WITH AN OSTOMY
A visit from another person with an ostomy can be very helpful in restoring self-esteem, and the local chapter of the United Ostomy Association can help you contact someone. It is much more effective if this person is someone of the same generation. We were able to locate an elderly person for one of our most severely depressed elderly patients. Initially, the patient refused such a visit, but seeing another senior citizen who also had an ostomy, but looked very spry and was an active member of the community, did wonders to boost her spirits.
USE KNOWLEDGE ABOUT TEACHING
Keeping in mind that it is dangerous to stereotype the elderly person in terms of cognitive changes or ability to learn, there are some guidelines for teaching the older adult with an ostomy that encompass some of the normal physiological and psychological changes of aging (Figure 1 ).
A major factor in the learning process is the perception of the stimulus by the learner's sensory system. Because the elderly person you are working with will, no doubt, have varying degrees of visual and auditory changes, you will have to make some adjustments. For example, most elderly people wear corrective lenses. Hand your patients their glasses before you begin your demonstration and check to be sure they are clean and properly fitted. Magnifiers can be very helpful. Remember that direct sunlight causes a glare, therefore, you may want to change position or close the curtain.
Unfortunately, many health teaching materials about ostomy care are in small print, so it may be helpful to develop some of your own with larger print that your patients can take home. If you do this, use bright colors such as red and yellow. It has been found that, as aging occurs, there is loss of color discrimination at the blue end of the color spectrum and loss of sensitivity over the entire spectrum. Pastel colors may become difficult to distinguish. Remember, too, that as the teacher you can enhance learning by wearing bright colors, bright lipstick, and a legible name pin.
If your elderly patient has a hearing loss, remember that low-pitched tones are better heard. In addition, the older person has difficulty discriminating pertinent sounds when there are background noises, so be sure to turn off the television set, radio, noisy air conditioner, or running faucet before you begin. If the patient is wearing a hearing aid, turn it on and make sure any ear wax is cleaned off the ear plugs.
Elderly patients need more time to process and react to information. In addition, speech perception decreases for the elderly as rate of speech increases. Speak slowly when teaching to allow your elderly ostomy patient to process the information. Proceed with your demonstration one step at a time and give plenty of time to process the information. In addition, avoid discussions that include long lists or numerous items.
Memory and Intellectual Capacity
Memory and intellectual capacity influence the older adult's learning in much the same way that they affect the younger adult; however, there are a few helpful observations. Many older adults have decreased short-term memory, which means that nurses should coach them to remember the demonstration they saw a few hours or the day before. Let them help you devise ways to remember the steps; they'll remember them much better.
Remember that intellectual functioning does not automatically deteriorate with age. In fact, the older we get, the more life experiences we have to build on. When teaching, ask your elderly patients to discuss what they have already heard about ostomies and their care before you start. Ask them if they have ever known anyone with an ostomy or if they have read anything about them and then build on this information.
Motivation is an absolutely essential ingrethent for learning in all age groups. The elderly must feel that what they are learning is meaningful and worthwhile. If they feel that someone else will take care of their ostomy when they get home, they will not be motivated to learn self-care. While teaching, emphasize that learning to care for their ostomies will allow them to be independent and return to the lifestyle they enjoyed before they had the ostomy.
In some instances, motivation to learn in the elderly patient with an ostomy is decreased by a fear of an inability to learn. Constant encouragement is necessary to alleviate their fears. Again, a visit from an elderly ostomy patient who is independent can increase motivation and decrease fears.
Energy and fatigue levels differ from the younger to the older adult and affect motivation. If possible, let your patient set the time for the teaching session. Ensure they have not taken any medications that will affect their ability to concentrate. It is best to avoid sessions after breakfast and bath when they are tired, because fatigue decreases motivation. Keep each session short. Again, ask the patients what they know before you explain it. No older adult likes to be patronized by hearing things he already knows.
Other chronic illnesses can get in the way of learning and performing ostomy care, for example, many older patients suffer from arthritic changes in their fingers, whereas others may have problems with peripheral neuropathy. If this is so, keep the system for pouching the stoma very simple but effective. A two-piece appliance may be the best choice for a 40-year-old, but it may be much too difficult for a 70- or 80-year-old. Perhaps it would be wise to look for an appliance that can be purchased pre-cut and is easy to apply. This does not mean that you will have to choose an appliance of inferior quality; some manufacturers have designed such products with the same pectin skin barrier found on the two-piece appliances. In addition, one-piece appliances allow fewer steps in pouch application. This is extremely helpful for elderly clients who will often feel overwhelmed if a series of steps is necessary to prepare the equipment (Figure 2).
One of our patients had osteoporosis with a shortening of her torso, making it necessary to choose an appliance without a flange to avoid her bony prominences (ribs and pelvic bones). We selected a one-piece drainable pouch with a pectin skin barrier.
Elderly patients often have been experiencing digestive problems for several months prior to surgery and their nutritional status is unsatisfactory. They get used to eating bland, simple foods that eliminate some of their preoperative symptoms but do not meet their nutritional needs. One method we used to educate a patient about her nutritional needs was to assist her in filling out her hospital menus. As she made her selections, we reminded her of the need for adequate protein, vegetables, and fluid.
For elderly colostomy patients, be sure to advise them to avoid foods that could cause gas, such as cabbage, cauliflower, cole slaw, and kidney beans. In addition, encourage them to avoid foods with a seed or shell, such as nuts and corn, since they can cause a mechanical food obstruction. It is also helpful to remind patients to chew their food well and to recommend that they have their dentures checked for proper fit as soon as they are well enough to see their dentist.
Sometimes, there may be problems as the diet is advanced. For example, we noticed that a patient barely touched her food when her diet was advanced to a house diet. She explained that she lost her appetite when she saw the large quantity of food at each meal. By giving her less food, but at more frequent intervals, we were able to establish an acceptable caloric intake.
Finally, it is important to remind elderly ostomy patients of the importance of drinking adequate liquids with meals and during the day. Keeping fresh water in the pitcher and reminding them to drink even when they do not feel thirsty reinforces the need for fluid intake (Figure 3).
Many elderly adults take a variety of medications prescribed by more than one physician. During a hospitalization, take the opportunity to review all medications and discuss them with the primary physician. You may need to enlist the help of a family member; for example, we asked a patient's daughter to bring all of her mother's medications to the hospital so that we could review them. We were amazed to find medicines that four physicians had prescribed. A few were drugs that, if taken in combination, could have caused serious complications.
We also discovered that she took a combination of a stool softener and a mild laxative every night. We alerted her physician, who instructed her to stop using these and reassured her that constipation would not be a problem with her type of ostomy. (Patients with a descending or sigmoid colostomy may experience constipation, but this is usually simply remedied with prune juice, magnesium hydroxide, or psyllium hydrophilic mucilloid.)
Upon discharge, this patient's medications were reduced to a daily dose of digoxin 0. 125 mg, furosemide 20 mg, and potassium chloride 30 mEq. We asked her physician to recommend that she take her potassium in a liquid form because we discovered the enteric coated tablet was not completely absorbed before being expelled through her stoma (Figure 4).
Teaching elderly patients the skills necessary to perform independent ostomy care may take a little more time and creativity than teaching younger persons, but returning them to their preoperative independent lifestyle is an attainable goal
It is tempting to simply take over and do the necessary ostomy care to save time. Ultimately, however, it is far better to take the extra time to teach patients what they must eventually learn if they are to return to a quality life after discharge.
TIPS FOR TEACHING THE ELDERLY PATIENT WITH AN OSTOMY