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Clinical Best
Practice Guidelines

AUGUST 2009

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Greetings from Doris Grinspun,

Executive Director Registered Nurses Association of Ontario
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Table of Contents
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4 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
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Purpose and Scope

879A=HEKD:
#FTU
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(Field & Lohr, 1990)

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3FHJTUFSFE
/VSTFT
BOE
3FHJTUFSFE

1SBDUJDBM
/VSTFT
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UP
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BOE
NBOBHFNFOU
PG
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XJUI
DPMPTUPNJFT
JMFPTUPNJFT

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PG
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BOE
GPMMPXVQ
"MM
JOEJ

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XJUI
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BDSPTT
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PG
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OFFET
PG
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BOE
DBSFHJWFS

XJMM
CF
BEESFTTFE

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JT
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UIBU
UIJT
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CF
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UP
BMM
EPNBJOT
PG
OVSTJOH
JODMVEJOH
DMJOJDBM
BE
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BOE
FEVDBUJPO

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  7
 0TUPNZ
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Summary of Recommendations
879A=HEKD:

Core Recommendations

RECOMMENDATION *Level of Evidence

1 Develop a therapeutic relationship with the client and family. III

2 Perform a comprehensive assessment of the client/family that includes: a) history and physical;
b) psychosocial (coping and adaptation, altered body image, impaired quality of life, sexuality
and sexual concerns); and c) cultural, spiritual and religious norms. III

3 Consult with interdisciplinary team members for assessment and intervention as needed for
all clients requiring, or who already have, an ostomy. IV

4 Design a mutually acceptable plan of care between the client/family and all health-care
providers, which optimizes health and self-efficacy in ostomy management. III

Practice Recommendations: Pre-Operative Phase

RECOMMENDATION Level of Evidence

5 Pre-operative education should be provided to all clients and families requiring ostomy surgery. Ib

6 Stoma site marking should be performed on all clients undergoing ostomy surgery. IIa

7 Explore the potential impact of ostomy surgery on intimacy and sexual functioning with
the client/partner. Ia

8 Progressive Muscle Relaxation Therapy (PMRT) should be offered to clients undergoing

ostomy surgery as part of routine care. Ib

4FF
QBHF
11
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FWJEFODF

8 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
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879A=HEKD:
Practice Recommendations: Post-Operative Phase

RECOMMENDATION Level of Evidence

9 Assess the stoma immediately post-operatively and the stoma/peristomal skin condition with
each appliance change using a validated classification tool to monitor for complications. IV

10 Identify risk factors that influence stomal and peristomal complications. III

11 Review the clients medication profile to ensure that maximum absorption and effectiveness
will be achieved in relation to the type of ostomy. IV

12 Avoid insertion of a glycerin suppository into a colostomy in order to aid evacuation of effluent. Ib

13 Counselling by a Registered Dietician should be performed for clients with an ostomy who are
at risk for, or who develop, nutritional complications. IIa

14 Prepare the client and family by teaching the minimum skill set specific to their needs prior
to discharge from hospital. IV

15 Discharge the client and family with home care support. Ib

16 Ensure that the ostomy plan of care is individualized to meet the needs of the client and family. IV

17 Assessment and follow-up by an Enterostomal Therapy Nurse (ETN) are recommended for the client
and family after ostomy surgery to decrease psychological distress, promote optimal quality of life
and prevent complications. IIb

18 Educate client and family members to recognize complications affecting the stoma and peristomal skin. IV

19 Colostomy irrigation may be implemented as a safe and effective method for the management
of descending or sigmoid colostomies for select adult clients. III

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  9
 0TUPNZ
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Education Recommendations

RECOMMENDATION Level of Evidence

879A=HEKD:

20 Ostomy education for all levels of health-care providers should be a systematic, client-centred
process, provided in both academic and workplace venues. IV

21 Consult ETNs in the development of ostomy educational programs that target appropriate
health-care providers, clients, family members and caregivers. IV

Organization & Policy Recommendations

RECOMMENDATION Level of Evidence

22 Organizations should utilize a credentialed ETN for policy development and program management. IV

23 All clients with ostomies, and their families, should have access to comprehensive education. IV

24 A mechanism must be in place for the transfer of information between care settings to
facilitate continued education and clinical support of the client. IV

25 Practice settings must have access to an interdisciplinary team of knowledgeable and skilled
health professionals to address quality care in ostomy management. IV

26 Nursing best practice guidelines can be successfully implemented only where there are IV
adequate planning, resources, organizational and administrative support, as well as appropriate
facilitation. Organizations may wish to develop a plan for implementation that includes:

n

An assessment of organizational readiness and barriers to implementation, taking into

account local circumstances.

n

Involvement of all members (whether in a direct or indirect supportive function) who will

contribute to the implementation process.

n

Ongoing opportunities for discussion and education to reinforce the importance of best practices.

n

Dedication of a qualified individual to provide the support needed for the education

and implementation process.

n
Ongoing opportunities for discussion and education to reinforce the importance of best practices.

n


Opportunities for reflection on personal and organizational experience in implementing guidelines.

10 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
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Interpretation of Evidence

879A=HEKD:
Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials.

Ib Evidence obtained from at least one randomized controlled trial.

IIa Evidence obtained from at least one well-designed controlled study without randomization.

IIb Evidence obtained from at least one other type of well-designed quasi- experimental study, without randomization.

III Evidence obtained from well-designed, non-experimental descriptive studies, such as comparative studies,
correlation studies and case studies.

IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.

Adapted from SIGN 50: A Guideline Developers Handbook (2008)

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  11
 0TUPNZ
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Development Panel Members

879A=HEKD:

Kathryn Kozell,
RN, MScN, APN(AC), Louise Forest-Lalande,
RN, MEd, ETN

CETN(c) $POTVMUJOH
.BOBHFS
JO
/VSTJOH
4DJFODFT
5FBN
-FBEFS $)6
4BJOUF+VTUJOF
1BTU
1SFTJEFOU
$"&5 .POUSnBM
2VnCFD
$PPSEJOBUPS
PG
2VBMJUZ
*OJUJBUJWFT
-POEPO
)FBMUI
4DJFODFT
$FOUSF Dr. Mikel Gray,
RN,
PhD, FNP, PNP, CUNP,
-POEPO
0OUBSJP CCCN, FAANP, FAAN

1SPGFTTPS
/VSTF
1SBDUJUJPOFS
Helen Abrams,
RD, CNSD
%FQBSUNFOU
PG
6SPMPHZ
BOE
4DIPPM
PG
/VSTJOH

3FHJTUFSFE
$MJOJDBM
%JFUJUJBO 6OJWFSTJUZ
PG
7JSHJOJB
6OJWFSTJUZ
)PTQJUBM $IBSMPUUFTWJMMF
7JSHJOJB
64"
-POEPO
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4DJFODFT
$FOUSF
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0OUBSJP Connie Lynne Harris,
RN, MSc, ETN
4FOJPS
$MJOJDBM
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0TUPNZ
8PVOET
Patti Barton,
RN, PHN, CETN(c) $BSF1BSUOFST
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0OUBSJP
4QFDJBMUZ
&5
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0OUBSJP Virginia McNaughton, RN, MPA,
CETN(c)
Nancy Bauer, HBA, HB Admin, RN, ETN
"EWBODFE
1SBDUJDF
$POTVMUBOU
3/"0
$IBNQJPO
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0TUPNZ
$POUJOFODF
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/VSTFT
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PG
0OUBSJP 4BJOU
&MJ[BCFUI
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$BSF
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0OUBSJP

Ruth Best,
RN, BA, ETN
Debbie Miller,
RN, BScN, MN, APN(AC),

4LJO
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/VSTF
$MJOJDJBO CETN(c)
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4DJFODFT
$FOUSF 0TUPNZ
4QFDJBMUZ
1SBDUJUJPOFS
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0OUBSJP 4VOOZCSPPL
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$FOUSF
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0OUBSJP
Karen Bruton,
RN, BScN(c), ETN
$MJOJDBM
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/VSTF Susan Mills-Zorzes,
RN, BScN, MDE,
/PSUIVNCFSMBOE
)JMMT
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$PCPVSH
0OUBSJP %JSFDUPS
$"&5
&OUFSPTUPNBM
5IFSBQZ

/VSTJOH
&EVDBUJPO
1SPHSBN
&OUFSPTUPNBM

Helen Fatum,
RN, BScN, ETN
5IFSBQZ
/VSTF
&OUFSPTUPNBM
5IFSBQJTU1BUJFOU
&EVDBUPS 4U
+PTFQIT
$BSF
(SPVQ
/PSUI
#BZ
(FOFSBM
)PTQJUBM 5IVOEFS
#BZ
0OUBSJP
/PSUI
#BZ
0OUBSJP

12 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

879A=HEKD:
Nancy Parslow,
RN, CETN(c) Samantha Mayo,
RN, MN
8PVOE
4QFDJBMUZ
/VSTF 3FTFBSDI
"TTJTUBOU
4PVUIMBLF
3FHJPOBM
)FBMUI
$FOUSF 3FHJTUFSFE
/VSTFT
"TTPDJBUJPO
PG
0OUBSJP
/FXNBSLFU
0OUBSJP 5PSPOUP
0OUBSJP

Colleen Simpson,
RN, BScN Rishma Nazarali,
RN, BScN, MN

4UBGG
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&MN
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0OUBSJP
5PSPOUP
0OUBSJP 5PSPOUP
0OUBSJP

Catherine Wood,
BMOS
1SPHSBN
"TTJTUBOU
3FHJTUFSFE
/VSTFT
"TTPDJBUJPO
PG
0OUBSJP
5PSPOUP
0OUBSJP

%FDMBSBUJPOT
PG
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BOE
DPOEFOUJBMJUZ
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CZ
BMM
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PG
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EFWFMPQNFOU

QBOFM
'VSUIFS
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GSPN
UIF
3FHJTUFSFE
/VSTFT
"TTPDJBUJPO
PG
0OUBSJP

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  13
 0TUPNZ
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Stakeholder Acknowledgement
879A=HEKD:

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/VSTFT

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/VSTJOH

#FTU
1SBDUJDF
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NAME, CREDENTIALS TITLE, ORGANIZATION, CITY, PROVINCE

DEBORAH ABNER, RN, BSc, MScN(A), ETN
&OUFSPTUPNBM
5IFSBQZ
/VSTF
$MJOJDJBO
.6)$

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)PTQJUBM
.POUSnBM
2VnCFD

SYLVIA ALLOY-KOMMUSAAR, RN
4VQFSWJTPS
&YUFOEJDBSF
7BO
%BFMF
4BVMU
4UF
.BSJF
0OUBSJP

JACQUELINE BAPTISTE-SAVOIE, RN,
8PVOE
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0TUPNZ
/VSTF
$MJOJDJBO

BScN, WOCN, CIC
5IF
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)PTQJUBM
4DBSCPSPVHI
0OUBSJP

JO-ANNE BILLINGS, RN
3/
"NCVMBUPSZ
$BSF
1SJNBSZ
/VSTF
6SPMPHZ
$MJOJD
5IF
$SFEJU

7BMMFZ
)PTQJUBM
.JTTJTTBVHB
0OUBSJP

DI BRACKEN, BA, BED
1SFTJEFOU
0TUPNZ
5PSPOUP
*NNFEJBUF
1BTU
1SFTJEFOU
*0"

1BTU
1SFTJEFOU
60"$
0TUPNZ
5PSPOUP
5PSPOUP
0OUBSJP

MONA BURROWS, RN(EC),
1SPGFTTPS
4U
-BXSFODF
$PMMFHF-BVSFOUJBO
6OJWFSTJUZ
#4D/

BScN, MSN, PHCNP
$PMMBCPSBUJWF
1SPHSBN
$PSOXBMM
0OUBSJP

STEPHANIE CHADWICK, RN,
8PVOE
$BSF

0TUPNZ
$POTVMUBOU

BScN, ET, MSc(C), IIWCC
4U
+PTFQIT
)FBMUI
$FOUSF
5PSPOUP
0OUBSJP

DEBRA CLARKE, RN
5FBN
-FBEFS
#
.FEJDBM4VSHJDBM
/PSUIVNCFSMBOE
)JMMT

)PTQJUBM
$PCPVSH
0OUBSJP

CAROL T. COKER, MSN, ARNP, CWOCN
1SFTJEFOU$&0
$5$
)FBMUIDBSF
$POTVMUJOH
*OD

1FNCSPLF
1JOFT
'MPSJEB
64"

SUZANNE COLLINS, RN, MS, $MJOJDBM
4QFDJBMJTU
.zMOMZDLF
)FBMUI
$BSF
$IBSMPUUF

CWOCN, DAPWCA
/PSUI
$BSPMJOB
64"

LYNN COWDREY-CARROLL, MSW, RSW
4VSHJDBM
$BSF
4PDJBM
8PSLFS
-POEPO
)FBMUI
4DJFODFT
$FOUSF

-POEPO
0OUBSJP

GAIL CREELMAN, RN, ET
&OUFSPTUPNBM
5IFSBQJTU
*8,
)FBMUI
$FOUSF
)BMJGBY
/PWB
4DPUJB

HEIDI H. CROSS, RN, MSN, FNP-BC, CWOCN
8PVOE

0TUPNZ
/VSTF
1SBDUJUJPOFS
46/:
6QTUBUF
.FEJDBM

6OJWFSTJUZ
)PTQJUBM
4ZSBDVTF
/FX
:PSL
64"

MIKE DORAZIO, ET, MMGT
0XOFS$POTVMUBOU
0TUPNZ
"TTPDJBUFT
#SPPNBMM
1FOOTZMWBOJB
64"

MICHELLE DAGLORIA, RN
$MJOJDBM
&EVDBUPS
1SPGFTTJPOBM
1SBDUJDF
-FBE
.FEJDJOF
(VFMQI

(FOFSBM
)PTQJUBM
(VFMQI
0OUBSJP

BARBARA DALE, RN, CWOCN, CHHN
%JSFDUPS
PG
8PVOE
$BSF
2VBMJUZ
)PNF
)FBMUI
-JWJOHTUPO

5FOOFTTFF
64"

14 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

DIANE GRGOIRE, RN, ET, BScN, MScN
4QJOB
#JEB
$PPSEJOBUPS
$IJMESFOT
)PTQJUBM
PG
&BTUFSO
0OUBSJP

0UUBXB
0OUBSJP

879A=HEKD:
LISA HEGLER, RN, BSN, CWOCN
&OUFSPTUPNBM
5IFSBQJTU
/VSTF
1SPWJEFODF
)FBMUI


4U
1BVMT
)PTQJUBM

7BODPVWFS
#SJUJTI
$PMVNCJB

KELLY HERON, RN, BScN, CWCN, COCN, ET
$MJOJDBM
1SBDUJDF
.BOBHFS

4VSHFSZ
&OUFSPTUPNBM
5IFSBQJTU

8JOETPS
3FHJPOBM
)PTQJUBM
8JOETPS
0OUBSJP

JO HOEFLOK, RN, BSN, MA, ET, CGN(C)
"EWBODFE
1SBDUJDF
/VSTF
(BTUSPFOUFSPMPHZ(FOFSBM
4VSHFSZ

4U
.JDIBFMT
)PTQJUBM
5PSPOUP
0OUBSJP

JENNIFER HUITSON, RN, BScN, MDE
4VSHJDBM
&EVDBUPS
3PTT
.FNPSJBM
)PTQJUBM

-JOETBZ
0OUBSJP

NATHAN KELLY, BScN STUDENT
4UVEFOU
#SPDL
6OJWFSTJUZ
4U
$BUIBSJOFT
0OUBSJP

RHODA KELLY-VOOGJARV, RB, BSN, ET
0GDF
/VSTF
%S
)BSSZ
.
7PPHKBSW
.FEJDBM
1SPGFTTJPOBM

$PSQPSBUJPO
5JNNJOT
0OUBSJP

LORI KING
$POTVNFS
3FQSFTFOUBUJWF
/PSUI
#BZ
0OUBSJP

LISA KIRK, RN, BSN, CWOCN
3FHJTUFSFE
/VSTF
$80$/
3JMFZ
)PTQJUBM
GPS
$IJMESFO
*OEJBOBQPMJT

*OEJBOB
64"


ANN KLEIN, RN, BScN, ETN
8PVOE0TUPNZ
4QFDJBMJTU
4VSHJDBM
4FSWJDFT
4PVUIMBLF
3FHJPOBM



)FBMUI
$FOUSF
/FXNBSLFU
0OUBSJP

JANE KORVER, RN, BAS, CWOCN
*OIPVTF
8PVOE0TUPNZ
/VSTF
.FSDZ
.FEJDBM
$FOUFS

$FEBS
3BQJET
*PXB
64"

LEE ANN KRAPFL, BSN, RN, CWOCN
8PVOE0TUPNZ
/VSTF
4QFDJBMJTU
.FSDZ
.FEJDBM
$FOUFS

%VCVRVF
*PXB
64"

LISA C. LYNCH, RN
5FBN
-FBEFS

4VSHFSZ
6OJU
2VFFOTXBZ
$BSMFUPO
)PTQJUBM

0UUBXB
0OUBSJP

ANTONINI MARIO, ET NURSE
&OUFSPTUPNBM
5IFSBQZ
/VSTF
-PDBM
)FBMUI
"VUIPSJUZ

&NQPMJ

*UBMZ

&NQPMJ
*UBMZ

LINA MARTINS, MScN, ET
$MJOJDBM
/VSTF
4QFDJBMJTU
&OUFSPTUPNBM
5IFSBQZ
/VSTF
4LJO

8PVOE
0TUPNZ
5FBN
4805

-POEPO
)FBMUI
4DJFODFT
$FOUSF


-POEPO
0OUBSJP

JOAN A. MCINERNEY, MSN, RN-BC, CWOCN
80$
/VSTF
$PPSEJOBUPS
/$)
)FBMUIDBSF
4ZTUFN

/BQMFT
'MPSJEB
64"

ESTRELLA C. MERCURIO, BSN, RN,
$BSF

4FSWJDF
.BOBHFS
1BSB.FE
)PNF
)FBMUI
$BSF

MA, GNC(C), ET
5PSPOUP
0OUBSJP

FAYE MILITANTE, RN, BSN, ET, CWON
&OUFSPTUPNBM
5IFSBQJTU
3/
1SPWJEFODF
4U
7JODFOU
.FEJDBM

$FOUFS
1PSUMBOE
0SFHPO
64"

SUSAN S. MORELLO, BSN, RN, CWOCN, CBN
$MJOJDBM
$PPSEJOBUPS
4J[FXJTF
,BOTBT
$JUZ
.JTTPVSJ
64"

ELISE NIELSEN, RN, BSN, ET
$MJOJDBM
$POTVMUBOU
8PVOET0TUPNZ
4BJOU
&MJ[BCFUI
)FBMUI
$BSF

.BSLIBN
0OUBSJP

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  15
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

LIZA PADILLA, RN, CGN(C), HONS BSc, BScN $MJOJDBM
$PPSEJOBUPS
5IF
0UUBXB
)PTQJUBM
0UUBXB
0OUBSJP

JOYCE PITTMAN, PhD(C),
/VSTF
1SBDUJUJPOFS$80$/
8PVOE0TUPNZ
5FBN

879A=HEKD:

APRN-BC, CWOCN
$MBSJBO
)FBMUI
*OEJBOBQPMJT
*OEJBOB
64"

ROSE RAIZMAN, RN, BScN, MSC, ET
$MJOJDBM
/VSTF
4QFDJBMJTU
&OUFSPTUPNBM
5IFSBQJTU

:PSL
$FOUSBM
)PTQJUBM
3JDINPOE
)JMM
0OUBSJP

VALERIE J. RZEPKA, RN, BScN, MSc
/VSTJOH
1PMJDZ
"OBMZTU
3FHJTUFSFE
/VSTFT
"TTPDJBUJPO
PG
0OUBSJP

5PSPOUP
0OUBSJP

CONNIE SCHULZ, RN, BN(C), ETN
$MJOJDBM
4QFDJBMJTU8PVOE

0TUPNZ
5IF
0UUBXB
)PTQJUBM

(FOFSBM
$BNQVT
0UUBXB
0OUBSJP

FAELYNNE SONKE, RN, BScN, CPN(C)
*OQBUJFOU
4VSHJDBM
$MJOJDBM
.BOBHFS
/JBHBSB
)FBMUI
4ZTUFN

4U
$BUIBSJOFT
0OUBSJP

DIANE ST-CYR, RN, ET, BSc, MED
&OUFSPTUPNBM
5IFSBQZ
/VSTF
.D(JMM
6OJWFSTJUZ
)FBMUI
$FOUSF

.POUSFBM
(FOFSBM
)PTQJUBM
$BNQVT
.POUSnBM
2VnCFD

JANE THERIAULT, BSN, RN, CWOCN
$MJOJDBM
$BSF
$PPSEJOBUPS
6OJWFSTJUZ
PG
.JDIJHBO
)PTQJUBM

"OO
"SCPS
.JDIJHBO
64"

KAREN THOMPSON, RN, BScN,
$MJOJDBM
1SBDUJDF
$POTVMUBOU
1BSB.FE
)PNF
)FBMUI

MED, CCHN(C)
-POEPO
0OUBSJP

RAMONA TOMSHACK, RN, BSN,
*OGFDUJPO
1SFWFOUJPOJTU80$ &5

4BSBI
#VTI
-JODPMO
)FBMUI

CIC, CWOCN, APN-CNS
$FOUFS
.BUUPPO
*MMJOPJT
64"

GWEN B. TURNBULL, RN, BS, ET
$POTVMUBOU
$MFBSXBUFS
'MPSJEB
64"

NANCY S. WALSH, RN, BS, CWOCN
.BOBHFS
PG
/VSTJOH
*OJUJBUJWFT
%BOCVSZ
)PTQJUBM

%BOCVSZ
$POOFDUJDVU
64"

KAREN WITKOWSKI, RN, BScN, ET
/VSTF
$MJOJDJBO&OUFSPTUPNBM
5IFSBQZ
5SJMMJVN
)FBMUI
$FOUSF

.JTTJTTBVHB
0OUBSJP

LAUREN WOLFE, RN, BSN, CWOCN
$80$/
3JDINPOE
)PTQJUBM
.JOPSV
3FTJEFODF
BOE
-JPOT

.BOPS
7BODPVWFS
$PBTUBM
)FBMUI
"VUIPSJUZ

3JDINPOE


#SJUJTI
$PMVNCJB

BONITA YARJAU, RN, BN, ET
$PPSEJOBUPS
&OUFSPTUPNBM
5IFSBQZ
1SPHSBN
)FBMUI
4DJFODFT

$FOUSF
8JOOJQFH
.BOJUPCB

MARY M. YODER, RN, MSN, CWON
8PVOE
BOE
0TUPNZ
$POTVMUBOU
"SLBOTBT
7BMMFZ
3FHJPOBM

.FEJDBM
$FOUFS
-B
+VOUB
$PMPSBEP
64"

16 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Background Context

879A=HEKD:
0TUPNZ
SFGFST
UP
B
TVSHJDBM
QSPDFEVSF
SFTVMUJOH
JO
UIF
FYUFSOBM
EJWFSTJPO
PG
GFDFT
BOE
VSJOF
UISPVHI

BO
BCEPNJOBM
TUPNB
5IF
NPTU
DPNNPO
PTUPNJFT
BSF
B
DPMPTUPNZ
BOE
JMFPTUPNZ
GPS
GFDFT
BOE
B

VSPTUPNZ
GPS
VSJOF
5IFTF
QSPDFEVSFT
BSF
QFSGPSNFE
PO
BMM
BHF
HSPVQT
GSPN
UIF
OFPOBUF
UP
UIF
FM
EFSMZ
4UBUJTUJDT
SFHBSEJOH
UIF
FYBDU
GSFRVFODZ
PG
PTUPNZ
TVSHFSZ
JO
$BOBEB
BSF
OPU
SFBEJMZ
BWBJMBCMF

IPXFWFS
B
DSPTTTFDUJPOBM
TVSWFZ
DPOEVDUFE
CZ
B
QSJWBUF
SFTFBSDI
HSPVQ
JO

SFWFBMFE
UIBU

BQQSPYJNBUFMZ
 
PTUPNZ
TVSHFSJFT
IBE
CFFO
QFSGPSNFE
EVSJOH
UIBU
QFSJPE
5IF
QSPWJODFT
SF
QPSUJOH
UIF
IJHIFTU
OVNCFS
PG
BOOVBM
QSPDFEVSFT
XFSF
SFTQFDUJWFMZ
0OUBSJP
2VFCFD
UIFO
#SJUJTI

$PMVNCJB
5IF
NPTU
GSFRVFOUMZ
QFSGPSNFE
PTUPNZ
JT
UIF
DPMPTUPNZ


GPMMPXFE
CZ
JMFPTUPNZ



BOE
VSPTUPNZ


0TUPNJFT
DBO
CF
FJUIFS
UFNQPSBSZ
PS
QFSNBOFOU
BOE
BSF
QFSGPSNFE
GPS

B
OVNCFS
PG
FUJPMPHJFT
TVDI
BT
CVU
OPU
MJNJUFE
UP
DPMPSFDUBM
DBODFS


JOGMBNNBUPSZ
CPXFM
EJT
FBTF


CMBEEFS
DBODFS


EJWFSUJDVMJUJT


OFDSPUJ[JOH
FOUFSPDPMJUJT
DPOHFOJUBM
BOPNB
MJFT
)JSTDITQSVOHT
EJTFBTF
BOE
PUIFS
DBODFST
BOE
DPOEJUJPOT
TVDI
BT
PCTUSVDUJPO
QFSGPSBUJPO

BOE
USBVNB
(The Oryx Group, 2001)
$PMPSFDUBM
DBODFS
SFTVMUJOH
JO
BO
PTUPNZ
JT
TFFO
NPSF
JO
NBMFT

XIFSFBT
PTUPNJFT
BT
B
SFTVMU
PG
BCEPNJOBM
DBODFST
BSF
OPUFE
NPSF
JO
GFNBMFT
"
VSPTUPNZ
GPS
CMBE
EFS
DBODFS
JT
QSFEPNJOBUFMZ
BTTPDJBUFE
XJUI
NBMFT
PTUPNJFT
SFMBUFE
UP
JOGMBNNBUPSZ
CPXFM
TVDI

BT
6MDFSBUJWF
$PMJUJT
BOE
$SPIOT
%JTFBTF
BSF
FYQFSJFODFE
FRVBMMZ
CZ
NBMFT
BOE
GFNBMFT
(Colwell,
Goldberg & Carmel, 2004)

5IF
QSPMF
PG
IFBMUI
DBSF
JO
$BOBEB
IBT
DIBOHFE
ESBNBUJDBMMZ
"O
BHJOH
QPQVMBUJPO
UIF
JODSFBTJOH

JODJEFODF
PG
DBODFST
(Canadian Cancer Society/National Cancer Institute of Canada, 2008)
BOE
UIF
BTTPDJ
BUFE
IFBMUI
EFNBOET
PG
DBSJOH
GPS
NVMUJQMF
TJNVMUBOFPVT
EJBHOPTFT
SFTVMUT
JO
MJGFMPOH
DBSJOH

5IF
)FBMUI
$PVODJM
PG
$BOBEB
IBT
GPDVTFE
JUT
BUUFOUJPO
PO
QSFWFOUJPO
BOE
NBOBHFNFOU
PG
DISPOJD

DPOEJUJPOT
UP
FODPVSBHF
EJTDVTTJPO
PG
UIF
DIBOHFT
UP
QVCMJD
QPMJDZ
IFBMUIDBSF
NBOBHFNFOU
BOE

IFBMUI
TFSWJDFT
EFMJWFSZ
SFRVJSFE
UP
JNQSPWF
IFBMUI
PVUDPNFT
GPS
$BOBEJBOT
(Broemeling et al., 2008)

$ISPOJD
DPOEJUJPOT
BGGFDU
BU
MFBTU
POF
UIJSE
PG
$BOBEJBOT
BOE
UIJT
QFSDFOUBHF
JODSFBTFT
XJUI
BHF
"T

NBOZ
PG
UIF
EJBHOPTFT
CFIJOE
BO
PTUPNZ
BSF
DISPOJD
DMJFOUT
XJUI
PTUPNJFT
XIFUIFS
UFNQPSBSZ
PS

QFSNBOFOU
GPSN
QBSU
PG
UIJT
DISPOJD
IFBMUI
DPOEJUJPO
QSPMF

*O
BMM
TFUUJOHT
GSPN
BDVUF
DBSF
UP
MPOHUFSN
DBSFSFTJEFOUJBM
PS
IPNF
B
DMJFOU
XJUI
BO
PTUPNZ
SF

RVJSFT
TQFDJBMJ[FE
DBSF
BOE
NBOBHFNFOU
UIBU
QSPNPUFT
JOEFQFOEFODF
BOE
RVBMJUZ
PG
MJGF
GPS
UIF
DMJ
FOU
GBNJMZ
BOE
DBSFHJWFST
*O
$BOBEB
BO
&OUFSPTUPNBM
5IFSBQZ
/VSTF
&5/

JT
B
3FHJTUFSFE
/VSTF

XIP
IBT
BEWBODFE
LOPXMFEHF
BOE
DMJOJDBM
TLJMM
QSFQBSBUJPO
GSPN
B
SFDPHOJ[FE
FEVDBUJPOBM
DFSUJDBUF

QSPHSBN
JO
UIF
NBOBHFNFOU
PG
PTUPNJFT
XPVOE
BOE
JODPOUJOFODF
TFF
"QQFOEJY
#

"T
B
OVSTJOH

TQFDJBMUZ
SFDPHOJ[FE
CZ
UIF
$BOBEJBO
/VSTFT
"TTPDJBUJPO
(March 2007)
&5/T
QSPWJEF
DMJOJDBM
FYQFS
UJTF
BOE
TVQQPSUJWF
DBSF
UP
DMJFOUT
BOE
GBNJMZ
NFNCFST
UISPVHIPVU
UIF
MJGF
TQBO
#Z
QSPNPUJOH
B

TUBOEBSE
PG
FYDFMMFODF
JO
PTUPNZ
DBSF
UISPVHI
FYQFSU
DPOTVMUBUJPO
FEVDBUJPO
BOE
FWJEFODFCBTFE

CFTU
QSBDUJDF
DMJFOUT
CFOFU
GSPN
UIF
DPOTJTUFODZ
BOE
DPOUJOVJUZ
PG
DBSF
EFMJWFSZ
GSPN
BMM
JOUFSEJTDJ
QMJOBSZ
UFBN
NFNCFST

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  17
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

5IF
QSPWJTJPO
PG
TQFDJBMJ[FE
PTUPNZ
DBSF
CFHJOT
QSFPQFSBUJWFMZ
DPOUJOVFT
UISPVHI
UIF
QPTUPQFS
BUJWF
BOE
SFIBCJMJUBUJWF
QFSJPE

JO
GBDU
UISPVHIPVU
UIF
MJGF
PG
B
DMJFOU
XJUI
BO
PTUPNZ
%VF
UP
UIF

OBUVSF
PG
B
DMJFOU
MJWJOH
XJUI
BO
PTUPNZ
GPS
MJGF
PTUPNZ
DBSF
BOE
NBOBHFNFOU
JT
TVQQPSUFE
CZ
UIF

879A=HEKD:

BWBJMBCJMJUZ
PG
PVUQBUJFOU
PTUPNZ
DMJOJDT
BOE
DPNNVOJUZ
DBSF
OVSTJOH
BHFODJFT
0OHPJOH
TUPNB
BOE

PTUPNZ
BQQMJBODF
TJ[JOH
UIF
USFBUNFOU
PG
QFSJTUPNBM
TLJO
DPNQMJDBUJPOT
PTUPNZ
BQQMJBODF
NPEJ
DBUJPOT
BDDFTT
UP
PTUPNZ
QSPEVDUT
BOE
OBODJBM
BTTJTUBODF
EJFUBSZ
DPOTVMUBUJPO
BOE
FNPUJPOBM

TVQQPSU
BSF
KVTU
B
GFX
PG
UIF
IFBMUI
NBOBHFNFOU
JTTVFT
SFRVJSFE
CZ
B
DMJFOU
BU
BOZ
UJNF
$MJFOU
TVQ
QPSU
DBO
BMTP
CF
GPVOE
UISPVHI
5IF
6OJUFE
0TUPNZ
"TTPDJBUJPO
PG
$BOBEB
60"$

XIJDI
IBT


DIBQUFST
DPVOUSZXJEF
BOE
NPSF
UIBO
 
NFNCFST
5IF
60"$
JT
B
WPMVOUFFS
CBTFE
PSHBOJ[BUJPO

EFEJDBUFE
UP
BTTJTUJOH
BMM
QFSTPOT
GBDJOH
MJGF
XJUI
HBTUSPJOUFTUJOBM
PS
VSJOBSZ
EJWFSTJPOT
CZ
QSPWJEJOH

FNPUJPOBM
TVQQPSU
JOTUSVDUJPOBM
BOE
JOGPSNBUJPO
TFSWJDFT
UISPVHI
UIF
NFNCFSTIJQ
UIF
GBNJMZ
BT
TPDJBUFE
DBSFHJWFST
BOE
UIF
HFOFSBM
QVCMJD
(United Ostomy Association of Canada, Personal Communica-
tion, September 22, 2008)

5IFSF
BSF
BQQSPYJNBUFMZ

&5/T
(The Canadian Association for Enterostomal Therapy, 2008) BDSPTT

$BOBEB
ZFU
UIF
EFNBOE
FYDFFET
UIF
BWBJMBCJMJUZ
GPS
UIJT
OVSTJOH
TQFDJBMUZ
"MUIPVHI
UIF
EFWFMPQNFOU

QBOFM
IBT
NBEF
FWFSZ
BUUFNQU
UP
QSPWJEF
UIF
CFTU
PG
UIF
SFTFBSDI
UP
TVQQPSU
UIF
SFDPNNFOEBUJPOT

JU
JT
BDLOPXMFEHFE
UIBU
UIF
TDJFODF
CFIJOE
UIF
QSBDUJDF
PG
FWJEFODFCBTFE
PTUPNZ
DBSF
BOE
NBOBHF
NFOU
JT
MJNJUFE
5IFSFGPSF
UIF
MFWFM
PG
FWJEFODF
PGUFO
SFFDUT
FYQFSU
PQJOJPO
BOE
SFGFSFODF
UP
HSFZ
MJUFSBUVSF
XIJDI
JT
SFGFSFODF
UP
VOQVCMJTIFE
EPDVNFOUT
PQJOJPO
QBQFST
BOE
DPOGFSFODF
NBUFSJBM
BT

FYBNQMFT (University of British Columbia, Searching for Grey Literature, Accessed July 31, 2008)
3FHJTUFSFE

/VSTFT
3FHJTUFSFE
1SBDUJDBM
/VSTFT
BOE
OPOSFHVMBUFE
IFBMUIDBSF
QSPWJEFST
XIP
BMTP
QSPWJEF
PT
UPNZ
DBSF
JO
BMM
TFUUJOHT
XJMM
CF
BCMF
UP
SFGFS
UP
BOE
VTF
UIJT
HVJEFMJOF
LOPXJOH
UIBU
JU
SFQSFTFOUT
UIF

CFTU
JO
UIF
PTUPNZ
IFBMUIDBSF
MJUFSBUVSF
UP
EBUF
BOE
FYDFMMFODF
JO
B
TUBOEBSE
PG
DBSF

5IJT
HVJEFMJOF
JT
EJWJEFE
JOUP
QSBDUJDF
QIBTFT
JO
PSEFS
UP
QSFTFOU
UIF
DPNQMFYJUZ
PG
UIF
DBSF
JTTVFT

BOE
OFFET
PG
UIF
DMJFOU
JO
B
MPHJDBM
NBOOFS
5IF
EFWFMPQNFOU
QBOFM
XPVME
MJLF
UP
JNQSFTT
VQPO
UIF

SFBEFS
UIBU
UIF
DBSF
BOE
NBOBHFNFOU
PG
DMJFOUT
XIP
IBWF
PTUPNJFT
JT
OPU
MJOFBS
BOE
UIBU
UIF
GSF
RVFOUMZ
DIBOHJOH
OFFET
PG
UIF
DMJFOU
NVTU
CF
SFFDUFE
JO
B
IJHIMZ
FYJCMF
ZFU
DPNQSFIFOTJWF
QMBO

PG
DBSF
EFMJWFSZ
5IF
QIBTFT
SFQSFTFOU
UIF
DMJFOUT
VOJRVF
KPVSOFZ
BOE
PGUFO
PWFSMBQ

18 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Core Recommendations
$PSF
SFDPNNFOEBUJPOT
BSF
UIPTF
UIBU
QSPWJEF
HVJEBODF
BDSPTT
UIF
DPOUJOVVN
PG
DBSF
JO
UIF
QSFPQFSB
UJWF
BOE
QPTUPQFSBUJWF
QFSJPET
BOE
BU
FWFSZ
JOUFSBDUJPO
XJUI
UIF
DMJFOU

RECOMMENDATION 1
:[l[befWj^[hWf[kj_Yh[bWj_edi^_fm_j^j^[Yb_[djWdZ\Wc_bo$
B[l[be\;l_Z[dY[3???

Discussion of Evidence

H ; 9 E C C ; D : 7J ? E D I
"
UIFSBQFVUJD
SFMBUJPOTIJQ
JT
HSPVOEFE
JO
BO
JOUFSQFSTPOBM
QSPDFTT
UIBU
PDDVST
CFUXFFO
UIF
OVSTF
BOE
UIF

DMJFOUGBNJMZ
5IF
UIFSBQFVUJD
SFMBUJPOTIJQ
JT
B
QVSQPTFGVM
HPBMEJSFDUFE
SFMBUJPOTIJQ
UIBU
JT
EJSFDUFE
BU

BEWBODJOH
UIF
CFTU
JOUFSFTU
BOE
PVUDPNF
PG
UIF
DMJFOU
(RNAO, 2002)

1SPGFTTJPOBM
OVSTJOH
PSHBOJ[BUJPOT
IBWF
JEFOUJFE
UIBU
B
UIFSBQFVUJD
SFMBUJPOTIJQ
PS
IFMQJOH
SFMBUJPO
TIJQ
JT
B
DFOUSBM
BTQFDU
PG
OVSTJOH
DBSF
BOE
IBT
FNCFEEFE
RVBMJUJFT
PG
UIF
OVSTFDMJFOU
SFMBUJPOTIJQ
JO

NBOZ
TUBUFNFOUT
PO
QSBDUJDF
(College of Nurses, 1999; RNAO, 2002)

5IF
RVBMJUJFT
PG
UIF
UIFSBQFVUJD
SFMBUJPOTIJQ
JODMVEF
BDUJWF
MJTUFOJOH
USVTU
SFTQFDU
HFOVJOFOFTT
FNQB

UIZ
BOE
SFTQPOEJOH
UP
UIF
DMJFOUT
DPODFSOT
(RNAO, 2002)

5IF
OVSTF
SFRVJSFT
TQFDJD
LOPXMFEHF
BCPVU
UIF
DMJFOU
IBWJOH
PTUPNZ
TVSHFSZ
BOE
UIF
OFFET
PG
UIF
DMJFOU

TP
UIBU
UIF
UIFSBQFVUJD
SFMBUJPOTIJQ
DBO
CF
FGGFDUJWF

5IF
OVSTF
OFFET
UP
LOPX
UIF
n DPOEJUJPO
PS
EJTFBTF
QSPDFTT
JNQBDUJOH
UIF
DMJFOU

n
SFBTPO
GPS
TVSHFSZ
SFRVJSJOH
B
UFNQPSBSZ
PS
QFSNBOFOU
PTUPNZ

n
UZQF
PG
PTUPNZ

n
FYQFDUFE
DBSF
SFRVJSFNFOUT
CBTFE
PO
DMJFOU
OFFE

n
DMJFOUT
VOEFSTUBOEJOH
BOE
QFSTQFDUJWF
PG
MJGF
XJUI
BO
PTUPNZ

n
BWBJMBCMF
TVQQPSU
OFUXPSL
GSPN
GBNJMZ
TJHOJDBOU
PUIFS
BOE
DPNNVOJUZ
SFTPVSDFT

5IFSBQFVUJD
SFMBUJPOTIJQT
CFHJO
QSFPQFSBUJWFMZ
UP
FTUBCMJTI
B
SBQQPSU
BOE
PCUBJO
BDDVSBUF
JOGPSNBUJPO

BCPVU
UIF
DMJFOUT
JOUFSQSFUBUJPO
BOE
GFFMJOHT
BCPVU
UIFJS
EJTFBTF
CPEZ
JNBHF
UIF
QSPQPTFE
TVSHFSZ

IPNF
MJGF
GBNJMZ
DJSDVNTUBODFT
BOE
SPMFT
BOE
SFMBUJPOTIJQT

)BVHFO
FU
BM
(2006)
VTFE
UIF
0TUPNZ
"EKVTUNFOU
4DBMF
0"4

UP
NFBTVSF
MPOHUFSN
PTUPNZ
BEKVTU
NFOU
JO

BEVMU
DMJFOUT
XJUI
QFSNBOFOU
DPMPTUPNJFT
JMFPTUPNJFT
PS
VSPTUPNJFT
"EKVTUNFOU
TDPSFT
PO

UIF
0"4
XFSF
IJHIFS
XIFO
UIF
DMJFOU
GPVOE
QSF
BOE
QPTUPQFSBUJWF
FEVDBUJPO
IFMQGVM
4DPSFT
XFSF
BMTP

IJHIFS
XIFO
PTUPNZ
FEVDBUJPO
XBT
BVHNFOUFE
CZ
UIF
QSFTFODF
PG
BO
&5/

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  19
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

1FSTTPO
BOE
-BSTTPO
(2005)
BENJOJTUFSFE
B
RVFTUJPOOBJSF
UIBU
NFBTVSFE
TBUJTGBDUJPO
XJUI
DBSF
GPMMPXJOH

PTUPNZ
TVSHFSZ
UP

QBUJFOUT
VOEFSHPJOH
PTUPNZ
TVSHFSZ
5IFZ
BMTP
GPVOE
UIBU
SFDFJWJOH
TBUJTGBDUPSZ

JOGPSNBUJPO
SFHBSEJOH
PTUPNZ
DBSF
XBT
XFJHIUFE
BT
UIF
NPTU
JNQPSUBOU
JOEJDBUPS
PG
RVBMJUZ
DBSF
GPMMPX
JOH
PTUPNZ
TVSHFSZ
5IFTF
SFTVMUT
BSF
TJNJMBS
UP
BO
FBSMJFS
TUVEZ
SFQPSUFE
CZ
1FSTTPO
FU
BM


UIBU

DPNQBSFE
QSFEJDUPST
PS
TBUJTGBDUJPO
WFSTVT
EJTTBUJTGBDUJPO
JO

DMJFOUT
XIP
VOEFSXFOU
PTUPNZ
TVSHFSZ

TJY
NPOUIT
PS
MPOHFS
QSJPS
UP
EBUB
DPMMFDUJPO
4BUJTGBDUJPO
XBT
BTTPDJBUFE
XJUI
UIF
PQQPSUVOJUZ
UP
DPNNV
OJDBUF
XJUI
UIF
&5/
BCPVU
UIFJS
IFBMUI
BOE
MJGF
TJUVBUJPO
BOE
EJTTBUJTGBDUJPO
XBT
BTTPDJBUFE
XJUI
QSFTFODF

PG
PTUPNZSFMBUFE
DPNQMJDBUJPOT
BOE
MBDL
PG
PQQPSUVOJUZ
UP
DPNNVOJDBUF
XJUI
UIF
&5/
BCPVU
UIFJS
IFBMUI

BOE
MJGF
TJUVBUJPO

.BSRVJT
.BSSFM
BOE
+BNCPO
(2003)
NFBTVSFE
RVBMJUZ
PG
MJGF
JO
 
DMJFOUT
XIP
IBE
VOEFSHPOF
PT
H ; 9 E C C ; D : 7J ? E D I

UPNZ
TVSHFSZ
GPS
B
WBSJFUZ
PG
DBODFSSFMBUFE
BOE
OPONBMJHOBOU
DPOEJUJPOT
TVDI
BT
JOBNNBUPSZ
CPXFM

EJTFBTF
3FTQPOEFOUT
XIP
JOEJDBUFE
UIBU
UIF
OVSTFT
XIP
QSPWJEFE
PTUPNZ
DBSF
BOE
XIP
IBE
B
HFOVJOF

JOUFSFTU
JO
UIF
SFTQPOEFOU
BT
B
QFSTPO
IBE
IJHIFS
RVBMJUZPGMJGF
JOEFY
TDPSFT
UIBO
UIPTF
XIP
JOEJDBUFE
B

QPPS
SFMBUJPOTIJQ
XJUI
UIF
OVSTFT
XIP
QSPWJEFE
UIFJS
PTUPNZ
DBSF

&SXJO5PUI
(1999)
SFQPSUFE
BO
FUIOPHSBQIZ
PG

ZPVOH
BEVMU
TVCKFDUT
XIP
SFDBMMFE
UIFJS
FYQFSJFODFT

BEKVTUJOH
UP
BO
PTUPNZ
XIFO
UIFZ
XFSF
CFUXFFO
TJY
BOE

ZFBSTPGBHF
"MM
PG
UIF
JOGPSNBOUT
TUBUFE
UIBU

GBNJMJFT
XFSF
JOVFOUJBM
JO
BEKVTUNFOU
UP
PTUPNZ
TVSHFSZ
1BSFOUT
XFSF
JEFOUJFE
BT
UIF
NPTU
JNQPSUBOU

TPVSDF
PG
TVQQPSU
BOE
TJCMJOHT
XFSF
JEFOUJFE
BT
BO
JNQPSUBOU
TFDPOEBSZ
SFTPVSDF
*OGPSNBOUT
XIP
XFSF

TFQBSBUFE
GSPN
B
QBSFOU
SFQPSUFE
EJGDVMUZ
BDIJFWJOH
B
TFOTF
PG
OPSNBMDZ
GPMMPXJOH
PTUPNZ
TVSHFSZ
OPU

SFQPSUFE
CZ
UIPTF
XIP
XFSF
SBJTFE
XJUI
QBSFOUT
BOE
TJCMJOHT
"MM
SFTQPOEFOUT
SFQPSUFE
MFBSOJOH
UP
DBSF

GPS
UIFJS
PTUPNZ
TPPO
BGUFS
TVSHFSZ
BOE
BMM
SFQPSUFE
QBSFOUT
BDUJWFMZ
QBSUJDJQBUJOH
JO
PTUPNZ
NBOBHF
NFOU

0MFKOJL
FU
BM
(2005)
TUVEJFE

QBSFOUT
XIPTF
DIJMESFO
VQ
UP
UXP
ZFBSTPGBHF

VOEFSXFOU
PTUPNZ
TVS
HFSZ
"MM
SFDFJWFE
TUPNB
DBSF
JOTUSVDUJPO
QSJPS
UP
TVSHFSZ
BOE
EVSJOH
UIF
JOJUJBM
IPTQJUBM
TUBZ

PG
QBS
FOUT
SFDBMMFE
SFDFJWJOH
BEFRVBUF
JOGPSNBUJPO
UP
DBSF
GPS
UIF
PTUPNZ
EVSJOH
UIF
JOJUJBM
IPTQJUBM
TUBZ


SFQPSUFE
SFDFJWJOH
BEFRVBUF
JOGPSNBUJPO
XJUIJO

IPVST
GPMMPXJOH
TVSHFSZ
BOE
BO
BEEJUJPOBM

SF
QPSUFE
SFDFJWJOH
BEFRVBUF
JOGPSNBUJPO
UP
NBOBHF
UIFJS
DIJMET
PTUPNZ
CZ
UIF
UJNF
PG
IPTQJUBM
EJTDIBSHF

&JHIUZ
UISFF
QFSDFOU
PG
QBSFOUT
TUBUFE
UIBU
PTUPNZ
FEVDBUJPO
QSPWJEFE
CZ
UIF
OVSTF
XBT
VOEFSTUBOEBCMF

5IF
BHF
BOE
FEVDBUJPOBM
MFWFM
PG
QBSFOUT
XBT
BTTPDJBUFE
XJUI
UIF
MJLFMJIPPE
PG
OEJOH
UIF
OVSTFT
JOTUSVD
UJPOT
VOEFSTUBOEBCMF
BOE
BQQMJDBCMF
UP
PTUPNZ
DBSF
ZPVOHFS
BOE
NPSF
IJHIMZ
FEVDBUFE
QBSFOUT
XFSF

NPSF
MJLFMZ
UP
VOEFSTUBOE
UFBDIJOH
UIBO
XFSF
PMEFS
BOE
MFTT
FEVDBUFE
QBSFOUT

5IFTF
EBUB
TVHHFTU
UIBU
QBSFOUT
BSF
UIF
NPTU
JNQPSUBOU
TPVSDF
GPS
DIJMESFO
BT
UIFZ
MFBSO
UP
NBOBHF
BOE

DPQF
XJUI
BO
PTUPNZ
1BSFOUT
JO
UVSO
SFMZ
PO
OVSTFT
UP
QSPWJEF
JOJUJBM
FEVDBUJPO
BCPVU
UIF
PTUPNZ
GPMMPX
JOH
TVSHFSZ
BOE
UIF
WBTU
NBKPSJUZ


BSF
TVDDFTTGVMMZ
UBVHIU
UP
CFHJO
DBSJOH
GPS
UIFJS
DIJMET
PTUPNZ

EVSJOH
UIF
JOJUJBM
IPTQJUBM
TUBZ
0MEFS
BOE
MFTT
FEVDBUFE
QBSFOUT
BSF
MJLFMZ
UP
SFRVJSF
NPSF
JOUFOTJWF
FEV
DBUJPO
BOE
TVQQPSU
UIBO
ZPVOHFS
BOE
NPSF
FEVDBUFE
QBSFOUT

5IFTF
OEJOHT
QSPWJEF
TVCTUBOUJBM
FWJEFODF
UIBU
GPSNBUJPO
PG
B
OVSTFDMJFOU
UIFSBQFVUJD
SFMBUJPOTIJQ

DPNQMFNFOUFE
CZ
DPOTVMUBUJPO
XJUI
BO
&5/
JT
JNQPSUBOU
GPS
TBUJTGBDUJPO
XJUI
DBSF
GPMMPXJOH
PTUPNZ

TVSHFSZ
GPS
MPOHUFSN
BEKVTUNFOU
UP
UIF
PTUPNZ
BOE
GPS
MFBSOJOH
UIF
TLJMMT
OFFEFE
GPS
TFMGNBOBHFNFOU

PG
UIF
PTUPNZ

20 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

RECOMMENDATION 2
F[h\ehcWYecfh[^[di_l[Wii[iic[dje\j^[Yb_[dj%\Wc_boj^Wj_dYbkZ[i0W^_ijehoWdZf^oi_YWb1
XfioY^eieY_WbYef_d]WdZWZWfjWj_ed"Wbj[h[ZXeZo_cW]["_cfW_h[ZgkWb_joe\b_\["i[nkWb_jo
WdZi[nkWbYedY[hdi1WdZYYkbjkhWb"if_h_jkWb"WdZh[b_]_ekidehci$
B[l[be\;l_Z[dY[3???

Discussion of Evidence

a) History and physical

H ; 9 E C C ; D : 7J ? E D I
"
QSFPQFSBUJWF
IJTUPSZ
BOE
QIZTJDBM
BTTFTTNFOU
QSPWJEFT
JOGPSNBUJPO
UIBU
XJMM
TFSWF
BT
CBTFMJOF
EBUB
GPS

EFWFMPQJOH
B
DPNQSFIFOTJWF
QMBO
PG
DBSF
"
DPOTFOTVT
PG
FYQFSU
PQJOJPO
TVQQPSUT
UIBU
UIJT
BTTFTTNFOU

TIPVME
JODMVEF

n
EFNPHSBQIJD
EBUB
JODMVEJOH
BHF
BOE
HFOEFS
n
EJBHOPTJT
BOE
DMJFOUT
QSFTFOUJOH
QSPCMFN

n
IJTUPSZ
PG
DMJFOUT
QSPCMFN

n
QSPHOPTJT
DVSBUJWF
PS
QBMMJBUJWF

n


TVSHJDBM
QMBO
JODMVEJOH
UZQF
PG
PTUPNZ
JMFPTUPNZ
VSPTUPNZ
DPMPTUPNZ


BOE
FYQFDUFE
EVSBUJPO

UFNQPSBSZ
QFSNBOFOU

n
DMJFOUT
BOE
GBNJMJFT
JOUFSQSFUBUJPO
PG
QSPTQFDUJWF
TVSHFSZ

n
QTZDIPMPHJDBM
QSFQBSFEOFTT
PG
DMJFOU
BOE
GBNJMZ

n
DMJFOUT
BOE
GBNJMJFT
JOUFSQSFUBUJPO
PG
MJGF
XJUI
BO
PTUPNZ

n


TPDJBM
IJTUPSZ
JODMVEJOH
PDDVQBUJPO
JOUFSQFSTPOBM
SFMBUJPOTIJQT
TFYVBMJUZ
DVMUVSBM
BOE
TQJSJUVBM

QSBDUJDFT
BOE
OBODJBM
DPOTJEFSBUJPOT
SFMBUFE
UP
PTUPNZ
TVQQMJFT
n


QIZTJDBM
BOE
DPHOJUJWF
DIBMMFOHFT
BOE
FOWJSPONFOUBMMJWJOH
DPOEJUJPOT
UIBU
DPVME
JNQBDU

MFBSOJOH
BOE
TFMGDBSF

n


GVODUJPOBM
BTTFTTNFOU
GPDVTJOH
PO
DPHOJUJWF
BOE
QTZDIPNPUPS
TLJMMT
OFFEFE
GPS
PTUPNZ

TFMGNBOBHFNFOU
JODMVEJOH
JEFOUJDBUJPO
PG
QBUJFOUT
XJUI
TQFDJD
QIZTJDBM
OFFET
TVDI
BT

JNQBJSFE
EFYUFSJUZ
TJHIU
PS
IFBSJOH

n

BCEPNJOBM
BTTFTTNFOU
GPS
TUPNB
TJUF
NBSLJOH
Modified from Borwell, (1996)

0TUPNZ
TVSHFSZ
SBEJDBMMZ
BMUFST
VSJOF
PS
GFDBM
FMJNJOBUJPO
GPSDJOH
UIF
DMJFOU
UP
MFBSO
OFX
QIZTJDBM
TLJMMT
JO

PSEFS
UP
NBOBHF
UIF
PTUPNZ
JUTFMG
GFDBM
PS
VSJOBSZ
FGVFOU
QSPEVDFE
CZ
UIF
PTUPNZ
BOE
UIF
QFSJTUPNBM
TLJO

(Persson & Helstrom, 2002)
$MJFOUT
XJUI
B
OFX
PTUPNZ
NVTU
NBTUFS
NVMUJQMF
QTZDIPNPUPS
TLJMMT
UP
SFNPWF

UIFJS
QPVDI
DMFBO
UIF
PTUPNZ
BOE
QFSJTUPNBM
TLJO
BOE
FNQUZ
BOE
EJTQPTF
PG
FGVFOU
GSPN
UIF
QPVDI

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  21
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

b) Psychosocial

0TUPNZ
TVSHFSZ
JT
BTTPDJBUFE
XJUI
NVMUJQMF
QTZDIPTPDJBM
DIBMMFOHFT
UIBU
OFHBUJWFMZ
JOVFODF
RVBMJUZ
PG

MJGF
20-

(Gooszen et al., 2000; de Gouveia Santos, Chaves & Kimura, 2006; Holzer et al., 2005; Karadag et al.,
2003; Krouse et al., 2007; Ma et al., 2007; Marquis, Marrel & Jambon, 2003; McVey, Madill & Fielding 2001; Nugent et
al., 1999; Ross et al., 2007; Scarpa et al., 2004; Wu, Chau & Twinn, 2007)
.D7FZ
.BEJMM
BOE
'JFMEJOH


FY
QMPSFE
QTZDIPMPHJDBM
DIBMMFOHFT
BTTPDJBUFE
XJUI
TUPNB
TVSHFSZ
BOE
MJWJOH
XJUI
BO
PTUPNZ
VTJOH
B
NJYFE

EFTJHO
UIBU
JODMVEFE
TFNJTUSVDUVSFE
JOUFSWJFXT
XJUI
FJHIU
TVCKFDUT
BOE
BENJOJTUSBUJPO
PG
WBSJPVT
WBMJEBU
FE
JOTUSVNFOUT
JO

BEEJUJPOBM
TVCKFDUT
5IFZ
JEFOUJFE
UIF
QIFOPNFOPO
PG
MPXFSFE
QFSTPOBM
DPOUSPM

BT
UIF
NBKPS
QTZDIPMPHJDBM
DIBMMFOHF
GBDJOH
QFSTPOT
VOEFSHPJOH
TUPNB
TVSHFSZ
BOE
MFBSOJOH
UP
BEKVTU
UP

BO
PTUPNZ
3FTVMUT
PG
UIFJS
SFTFBSDI
JOEJDBUF
UIBU
PTUPNZ
TVSHFSZ
BOE
EJBHOPTJT
PG
UIF
VOEFSMZJOH
EJTFBTF

H ; 9 E C C ; D : 7J ? E D I

MFBEJOH
UP
JUT
DSFBUJPO
JOJUJBMMZ
DSFBUFT
BO
VODPNGPSUBCMF
EFQFOEFODZ
BTTPDJBUFE
XJUI
EJTUSFTTJOH
FNP
UJPOT
JODMVEJOH
EFQSFTTJPO
BOE
BOYJFUZ
BOE
QSPNQUJOH
NVMUJQMF
EFGFOTJWF
TUSBUFHJFT
&OBCMJOH
GBDUPST

JODMVEJOH
FEVDBUJPO
BOE
TVQQPSU
GSPN
OVSTFT
BOE
FNPUJPOBM
TVQQPSU
BOE
FODPVSBHFNFOU
GSPN
GBNJMJFT

BTTJTU
UIF
QBUJFOU
UP
SFDPWFS
B
QBSUJBM
TFOTF
PG
BVUPOPNZ
&EVDBUJPO
CFGPSF
BOE
BGUFS
TVSHFSZ
OFFET
UP
CF
BO

POHPJOH
QSPDFTT
(Persson & Hellstrom, 2002)
-POHUFSN
SFDPWFSZ
JT
DIBSBDUFSJ[FE
JOJUJBMMZ
CZ
UBLJOH
DPOUSPM

PG
PTUPNZ
DBSF
GPMMPXFE
CZ
TFFLJOH
UP
SFDPWFS
B
TFOTF
PG
OPSNBMDZ
BOE
SFFTUBCMJTIJOH
XPSLSFMBUFE
BOE

TPDJBM
BDUJWJUJFT
5IF
EFTJSF
UP
SFHBJO
B
TFOTF
PG
OPSNBMDZ
BMTP
FNFSHFT
BT
B
NBKPS
UIFNF
PG
SFDPWFSZ
JO

&SXJO5PUIT
FUIOPHSBQIZ
(1999)
PG
ZPVOH
BEVMUT
XIP
VOEFSXFOU
PTUPNZ
TVSHFSZ
BT
DIJMESFO

Coping and adaptation

3FZOBVE
BOE
.FFLFS
(2002)
BENJOJTUFSFE
B
NPEJFE
+BMPXFJD
$PQJOH
4DBMF
UIBU
RVFSJFE

DPQJOH

NFUIPET
JO

BEVMUT
XJUI
JMFPTUPNJFT
PS
DPMPTUPNJFT
XIP
XFSF
BHF

ZST
$POGSPOUJWF
DPQJOH
TUSBU
FHJFT
UIBU
GPDVTFE
PO
TFMG
SFMJBODF
JO
PTUPNZ
NBOBHFNFOU
XFSF
NPTU
DPNNPOMZ
VTFE
UP
BEKVTU
UP
MJWJOH

XJUI
BO
PTUPNZ
BTTPDJBUFE
XJUI
DBODFS
PS
JOBNNBUPSZ
CPXFM
EJTFBTF
$BSMTTPO
FU
BM
(2001)
BMTP
GPVOE

UIBU
B
DPOGSPOUBUJPOBM
DPQJOH
TUZMF
XBT
NPTU
DPNNPOMZ
FNQMPZFE
JO
UIFJS
TUVEZ
PG

TVCKFDUT
XJUI

JMFPTUPNJFT
PXJOH
UP
JOBNNBUPSZ
CPXFM
EJTFBTF
8V
$IBV
BOE
5XJOO
(2007)
BENJOJTUFSFE
B
$IJOFTF

WFSTJPO
PG
UIF
4'
BOE
4UPNB
4FMG&GDBDZ
4DBMF
UP

TVCKFDUT
GSPN
UXP
BDVUF
DBSF
GBDJMJUJFT
JO
$IJOB

5IFZ
BMTP
GPVOE
B
QPTJUJWF
DPSSFMBUJPO
CFUXFFO
IJHIFS
TFMGFGDBDZ
BOE
IFBMUI
SFMBUFE
20-
%F
(PVWFJB

4BOUPT
$IBWFT
BOE
,JNVSB


DPNQBSFE
DPQJOH
TUZMFT
JO

TVCKFDUT
XJUI
UFNQPSBSZ
PTUPNJFT
UP


TVCKFDUT
XJUI
QFSNBOFOU
PTUPNJFT
VTJOH
UIF
-B[BSVT

'PMLNBO
$PQJOH
4USBUFHJFT
*OWFOUPSZ
BOE

UIF
'FSSBOT

1PXFMM
20-
*OWFOUPSZ
4VCKFDUT
XJUI
UFNQPSBSZ
PTUPNJFT
UFOEFE
UP
VTF
FTDBQFBWPJEBODF

TUSBUFHJFT
UP
DPQF
XJUI
UIFJS
PTUPNJFT
XIJMF
UIPTF
XJUI
QFSNBOFOU
TUPNBT
UFOEFE
UP
VTF
B
DPOGSPOUB
UJPOBM
TUZMF
GPDVTJOH
PO
QMBOOFE
QSPCMFN
TPMWJOH
BOE
TFMGSFMJBODF

5IFTF
EBUB
TUSPOHMZ
TVHHFTU
UIBU
PTUPNZ
QBUJFOUT
NVTU
EFBM
XJUI
UIF
QTZDIPMPHJDBM
DIBMMFOHFT
BTTPDJBUFE

XJUI
MPXFSFE
QFSTPOBM
DPOUSPM
FTQFDJBMMZ
EVSJOH
UIF
JNNFEJBUF
QPTUPQFSBUJWF
SFDPWFSZ
5IF
NPTU
DPN
NPO
DPQJOH
TUZMFT
VTFE
XJUI
UIJT
QTZDIPMPHJDBM
DIBMMFOHF
BSF
DPOGSPOUBUJPOBM
TUSBUFHJFT
EFTJHOFE
UP
SFHBJO

BVUPOPNZ
JO
PTUPNZ
NBOBHFNFOU
BOE
SFFTUBCMJTI
B
TFOTF
PG
TFMGFGDBDZ
.D7FZ
.BEJMM
BOE
'JFMEJOH



3FZOBVE
BOE
.FFLFS


BOE
8V
$IBO
BOE
5XJOO
(2007)
BMM
PCTFSWFE
UIBU
OVSTJOH
JOUFSWFO
UJPOT
UIBU
FOBCMF
DMJFOUT
UP
JODSFBTF
TFMGFGDBDZ
JO
PTUPNZ
NBOBHFNFOU
BDU
BT
FOBCMFST
BT
UIFZ
TUSVHHMF
UP

SFFTUBCMJTI
B
TFOTF
PG
OPSNBMDZ
GPMMPXJOH
PTUPNZ
TVSHFSZ

22 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Altered body image

#PEZ
JNBHF
JT
EFOFE
BT
UIF
JOEJWJEVBMT
QFSDFQUJPO
PG
QIZTJDBM
BQQFBSBODF
BOE
QIZTJDBM
GVODUJPO
$MJ
FOUT
XJUI
BO
PTUPNZ
DPOTJTUFOUMZ
SFQPSU
B
DIBOHF
JO
CPEZ
JNBHF
BT
B
EJSFDU
SFTVMU
PG
UIFJS
TVSHFSZ
(Holzer
et al., 2005; Krouse et al., 2007; Marquis, Marrel & Jambon, 2003; Notter & Burnard, 2006; Persson & Helstrom, 2002;
Piwonka & Merino, 1999; Ross et al., 2007)
#SPXO
BOE
3BOEMF
(2005)
TZTUFNBUJDBMMZ
SFWJFXFE
UIF
MJUFSBUVSF

BOE
OPUFE
UIBU
XPNFO
UFOEFE
UP
SFQPSU
UIBU
CPEZ
JNBHF
GBDUPST
XFSF
UIF
NPTU
OFHBUJWF
BTQFDU
PG
TUPNB

TVSHFSZ
*NQBJSFE
CPEZ
JNBHF
JT
BTTPDJBUFE
XJUI
TZNQUPNT
PG
XFBLOFTT
GSBHJMJUZ
VOBUUSBDUJWFOFTT
BOE

GFFMJOHT
PG
TUJHNB
1FSTTPO
BOE
)FMTUSPN


SFQPSUFE
B
QIFOPNFOPMPHJDBM
TUVEZ
PG
OJOF
TVCKFDUT

XIP
FNQIBTJ[FE
UIF
JOJUJBM
TIPDL
BOE
FNPUJPOBM
EJTUSFTT
UIFZ
FYQFSJFODFE
XIFO
UIF
TUPNB
XBT
STU
WJ
TVBMJ[FE
"
DMBTTJD
TUVEZ
BEESFTTJOH
UIJT
JTTVF
OPUFE
UIBU
JNQBJSFE
CPEZ
JNBHF
NBZ
QFSTJTU
GPS
BT
MPOH
BT

H ; 9 E C C ; D : 7J ? E D I

ZFBST
GPMMPXJOH
DSFBUJPO
PG
BO
PTUPNZ
0SCBDI

5BMMFOU



Impaired quality of life

'JOEJOHT
GSPN
FYJTUJOH
SFTFBSDI
DPOTJTUFOUMZ
EFNPOTUSBUF
UIBU
VOEFSHPJOH
PTUPNZ
TVSHFSZ
JOJUJBMMZ
JNQBJST

IFBMUISFMBUFE
20-
(Gooszen et al., 2000; Holzer et al., 2005; Karadag et al., 2003; Krouse et al., 2007; Ma et al., 2007;
Marquis, Marrel & Jambon, 2003; McVey, Madill, & Fielding 2001; Nugent et al., 1999; Ross et al., 2007; Scarpa et al.,
2004; Wu, Chau & Twinn, 2007)
.BSRVJT
.BSSFM
BOE
+BNCPO
(2003

BENJOJTUFSFE
B
WBMJEBUFE
20-
JOTUSVNFOU

UP
SFTQPOEFOUT
XJUI
DPMPTUPNJFT
JMFPTUPNJFT
BOE
VSPTUPNJFT
BU
IPTQJUBM
EJTDIBSHF
BOE
BU
UISFF
TJY
OJOF

BOE

NPOUIT
GPMMPXJOH
EJTDIBSHF
"OBMZTJT
SFWFBMFE
UIBU
20-
TDPSFT
TUFBEJMZ
SPTF
EVSJOH
UIF
STU
ZFBS
GPM
MPXJOH
PTUPNZ
DSFBUJPO
CVU
UIF
POMZ
TUBUJTUJDBMMZ
TJHOJDBOU
EJGGFSFODF
PDDVSSFE
CFUXFFO
IPTQJUBM
EJTDIBSHF

BOE
UISFF
NPOUIT
.B
FU
BM
(2007)
FWBMVBUFE
UIF
FGGFDU
PG
BHF
PO
20-
PWFS
UIF
STU

NPOUIT
GPMMPXJOH

PTUPNZ
TVSHFSZ
JO
B
HSPVQ
PG

TVCKFDUT
NFEJBO
BHF

ZFBST
SBOHF

ZFBST

BU
IPTQJUBM
EJTDIBSHF

BOE
BHBJO
BU
TJY
BOE

NPOUIT
"EVMUT
BHF

ZFBST
BOE
PMEFS
UFOEFE
UP
IBWF
JOJUJBMMZ
IJHIFS
20-
TDPSFT

UIBO
EJE
ZPVOHFS
BEVMUT
CVU
UIFZ
EJE
OPU
FYQFSJFODF
UIF
HSBEVBM
HBJOT
JO
20-
PWFS
UIF
STU
QPTUPQFSBUJWF

ZFBS
5IFTF
OEJOHT
QSPWJEF
B
DPNQFMMJOH
SBUJPOBMF
UIBU
BENJOJTUSBUJPO
PG
B
WBMJEBUFE
DPOEJUJPOTQFDJD
PS

HFOFSJD
20-
JOTUSVNFOU
JT
SFDPNNFOEFE
UP
FTUBCMJTI
UIF
JNNFEJBUF
FGGFDU
PG
PTUPNZ
TVSHFSZ
PO
20-
BOE

UP
FOBCMF
MPOHJUVEJOBM
NFBTVSFNFOU
BT
UIF
QBUJFOU
BEKVTUT
UP
MJWJOH
XJUI
BO
PTUPNZ

Sexuality and sexual concerns

&YJTUJOH
SFTFBSDI
DPOTJTUFOUMZ
SFWFBMT
UIBU
DMJFOUT
XJUI
PTUPNJFT
FYQFSJFODF
BOYJFUZ
BOE
FYQSFTT
DPODFSOT

BCPVU
TFYVBM
JTTVFT
(Campo et al., 2003; Carlsson, Berglund & Nordgren, 2001; Cheng, 2001; Erwin-Toth, 1999;
Karadag et al., 2003; Krouse et al., 2007; Nordstrom & Nyman, 1991; Nugent et al., 1999; Persson & Hellstrom 2002;
Piwonka & Marino, 1999; Prieto, Thorsen & Juul, 2005; Ross et al., 2007; Salter 1992)
#SPXO
BOE
3BOEMFT
(2005)

TZTUFNBUJD
SFWJFX
SFQPSUFE
TFYVBM
EZTGVODUJPO
JO

PG
QFSTPOT
VOEFSHPJOH
DPMPTUPNZ
BOE
FSFDUJMF
EZT
GVODUJPO
JO

PG
NFO
VOEFSHPJOH
SBEJDBM
DZTUFDUPNZ
BOE
VSPTUPNZ
3JDICPVSH
FU
BM
(2007)
TUBUFE
UIBU


PG
DPMPTUPNZ
QBUJFOUT

PG
JMFPTUPNZ
QBUJFOUT
BOE

PG
VSPTUPNZ
QBUJFOUT
FYQFSJFODFE
TFYVBM

QSPCMFNT
GPMMPXJOH
PTUPNZ
TVSHFSZ
ZJFMEJOH
B
QSFWBMFODF
SBUF
PG

JO
BMM
QFSTPOT
XJUI
BO
PTUPNZ

4FYV
BMJUZ
JT
BO
JOUFHSBM
QBSU
PG
RVBMJUZ
PG
MJGF
BOE
DMPTFMZ
MJOLFE
XJUI
CPEZ
JNBHF
1FSTTPOT
HSPVQ
(Persson & Lars-
son, 2005; Persson et al., 2005)
SFQPSUFE
UIBU
OVSTFT
DPODFSO
BCPVU
DMJFOUT
TFYVBM
QSPCMFNT
JT
B
DPNQPOFOU

PG
UIFJS
QFSDFQUJPOT
PG
TBUJTGBDUJPO
XJUI
DBSF
5IJT
EBUB
QSPWJEF
SBUJPOBMF
GPS
FWBMVBUJOH
TFYVBM
QSPCMFNT

GPMMPXJOH
PTUPNZ
TVSHFSZ

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  23
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

c) Cultural, spiritual and religious norms

5IF
5SBOTDVMUVSBM
/VSTJOH
4PDJFUZ
EFOFT
DVMUVSF
BT
OPSNT
BOE
QSBDUJDFT
PG
B
QBSUJDVMBS
HSPVQ
UIBU
BSF

MFBSOFE
BOE
TIBSFE
BOE
HVJEF
UIJOLJOH
EFDJTJPOT
BOE
BDUJPOT
$VMUVSBMMZ
EJWFSTF
OVSTJOH
DBSF
JT
EFOFE
BT

UIF
WBSJBCMF
BQQSPBDIFT
OFFEFE
UP
QSPWJEF
DVMUVSBMMZ
BQQSPQSJBUF
DBSF
UIBU
JODPSQPSBUFT
UIF
DMJFOUT
DVMUVSBM

WBMVFT
CFMJFGT
BOE
QSBDUJDFT
JODMVEJOH
TFOTJUJWJUZ
UP
UIF
JOEJWJEVBMT
FOWJSPONFOU
BOE
UIF
FOWJSPONFOU
UP

XIJDI
UIF
JOEJWJEVBM
NBZ
VMUJNBUFMZ
SFUVSO
(Leininger, 1991)

4QJSJUVBMJUZ
JT
EJGGFSFOUJBUFE
GSPN
SFMJHJPO
SFMJHJPO
JT
UIF
TPDJBM
JOTUJUVUJPO
PG
CFMPOHJOH
CFMJFGT
SJUFT

BOE
DVTUPNT
(Zinnbauer et al., 1997)
XIJMF
TQJSJUVBMJUZ
JT
UIF
JOEJWJEVBMT
QFSTPOBM
TUBUF
PG
XFMMCFJOH
PQUJ
NJTN
QVSQPTF
BOE
CFMJFG
JO
UIF
NFBOJOH
PG
MJGF
(Miller & Thoreson, 2003; Zinnbauer et al., 1997)
#BMEXJO
FU

H ; 9 E C C ; D : 7J ? E D I

BM
(2008)
JO
B
RVBMJUBUJWF
TUVEZ
EFTDSJCF
UIF
JOVFODF
PG
MJWJOH
XJUI
BO
JOUFTUJOBM
TUPNB
PO
UIF
TQJSJUVBM

RVBMJUZ
PG
MJGF
VTJOH
UIF
$JUZ
PG
)PQF
20-
0TUPNZ
.FBTVSF
IUUQQSDDPIPSHQEG2VBMJUZPG
-JGF0TUPNZQEG

1BSUJDJQBOUT
XFSF
MJNJUFE
UP
NBMF
64
7FUFSBOT
BOE
BT
TVDI
UIF
SFTVMUT
DBOOPU
CF

BQQMJFE
UP
UIF
HFOFSBM
QPQVMBUJPO
)PXFWFS
UIF
SFTVMUT
JOEJDBUFE
UIBU
UIFTF
JOEJWJEVBMT
WBSJFE
HSFBUMZ
JO

UIFJS
SFTQPOTFT
UP
JUFNT
UIBU
XFSF
XJUIJO
UIF
TQJSJUVBM
EPNBJO
TVDI
BT
TFOTF
PG
JOOFS
QFBDF
GFFMJOH

IPQFGVM
BOE
B
SFBTPO
UP
CF
BMJWF
BT
XFMM
BT
EFTDSJCJOH
UIFJS
TVQQPSU
JO
TQJSJUVBM
BDUJWJUJFT
MJLF
NFEJUB
UJPO
PS
QSBZFS
PS
SFMJHJPVT
BDUJWJUJFT
EFOFE
BT
BUUFOEJOH
DIVSDI
PS
UFNQMF
5IF
BVUIPST
QSPWJEF
UXP

FYBNQMFT
PG
UIF
TJHOJDBOU
WBSJBODF
JO
SFTQPOTFT
POF
JOEJWJEVBM
JO
UIF
IJHI
RVBSUJMF
SFTQPOTF
FYQSFTTFE

QPTJUJWF
DIBOHFT
BT
BO
PQQPSUVOJUZ
UP
DIBOHF
NZ
MJGF
GPS
UIF
CFUUFS
JO
UIF
UJNF
UIBU
XBT
MFGU

BT
PQ
QPTFE
UP
B
SFTQPOEFOU
JO
UIF
MPXFS
RVBSUJMF
SBOHF
XIP
EFTDSJCFE
UIF
TVSHJDBM
QSPDFEVSF
BT
B
DSPXOJOH

OFHBUJWF
QPTJUJWF
UIJOH
UIBU
BTTJTUFE
XJUI
XBLJOH
VQ
UP
XIBU
MJGF
XBT
BMM
BCPVU

4FWFSBM
SFMJHJPVT
BOE
TQJSJUVBM
GBDUPST
NBZ
JOVFODF
UIF
JOEJWJEVBMT
SFTQPOTF
UP
PTUPNZ
TVSHFSZ
JODMVE
JOH
SFMJHJPVT
CFMJFGT
EFHSFF
PG
SFMJHJPTJUZ
BOE
TQFDJD
SFMJHJPVT
BOE
TQJSJUVBM
DVTUPNT
PCTFSWFE
JO
EBJMZ

MJGF
'VSUIFS
SFTFBSDI
JT
OFFEFE
UP
CFUUFS
PVS
VOEFSTUBOEJOH
PG
IPX
UIFTF
SFTQPOTFT
NBZ
DIBOHF
BGUFS

PTUPNZ
TVSHFSZ
(Baldwin et al., 2008)

)PM[FS
FU
BM
(2005)
BENJOJTUFSFE
B
WBMJEBUFE
20-
JOTUSVNFOU
UP

QFSTPOT
MJWJOH
XJUI
BO
PTUPNZ
JO


TJUFT
JO
&VSPQF
BOE
UIF
.FEJUFSSBOFBO
"MUIPVHI
UIFJS
SFTFBSDI
XBT
EFTJHOFE
UP
FWBMVBUF
EJGGFSFODFT

CBTFE
PO
HFPHSBQIJD
SFHJPO
UIFZ
SFQPSUFE
UIBU
QFSTPOT
XJUI
BO
*TMBNJD
DVMUVSBM
IFSJUBHF
IBE
MPXFS
20-

TDPSFT
UIBO
PUIFS
SFTQPOEFOUT
SFHBSEMFTT
PG
HFPHSBQIJD
PSJHJO
,V[V
FU
BM
(2002)
TUVEJFE
20-
JO


.VTMJN
QBUJFOUT
VOEFSHPJOH
USFBUNFOU
PG
SFDUBM
DBODFS
"
TJHOJDBOUMZ
IJHIFS
QPSUJPO
PG
TVCKFDUT
XIP

VOEFSXFOU
BCEPNJOPQFSJOFBM
SFTFDUJPO
BOE
DSFBUJPO
PG
B
DPMPTUPNZ
SFQPSUFE
UIBU
UIFZ
GFMU
DPNQFMMFE
UP

TUPQ
QSBZJOH
BOE
GBTUJOH
UIBO
EJE
TVCKFDUT
USFBUFE
CZ
TQIJODUFS
TBWJOH
DPMPOJD
SFTFDUJPO
PS
BOUFSJPS
SFTFD
UJPO
)PXFWFS
,V[V
FU
BM
(2002)
GPVOE
UIBU
GPS
UIPTF
JOEJWJEVBMT
XIP
TUPQQFE
QSBZJOH
JO
NPTRVFT
PS

BMPOF
GPMMPXJOH
UIFJS
PTUPNZ
TVSHFSZ
TPDJBM
BDUJWJUZ
XBT
TJHOJDBOUMZ
JNQBJSFE
DPNQBSFE
UP
UIPTF
XIP

DPOUJOVFE
UP
EP
CPUI
1



"MUIPVHI
FYJTUJOH
FWJEFODF
JT
TQBSTF
UIFTF
EBUB
TVHHFTU
UIBU
DVMUVSBM
DPOTJEFSBUJPOT
JOVFODF
BEKVTU
NFOU
UP
BO
PTUPNZ
BOE
UIBU
BTTFTTNFOU
PG
B
DMJFOUT
DVMUVSBM
IFSJUBHF
JT
BO
FTTFOUJBM
DPNQPOFOU
PG
B

DPNQSFIFOTJWF
OVSTJOH
FWBMVBUJPO
5IFZ
SFDPNNFOE
UIBU
JOEJWJEVBMT
PG
UIF
.VTMJN
GBJUI
CF
DPVOTFMMFE

QSF
BOE
QPTUPTUPNZ
TVSHFSZ
SFHBSEJOH
SFMJHJPVT
MJGF
BMUFSBUJPO

24 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

RECOMMENDATION 3
9edikbjm_j^_dj[hZ_iY_fb_dWhoj[Wcc[cX[hi\ehWii[iic[djWdZ_dj[hl[dj_edWid[[Z[Z\ehWbbYb_[dji
h[gk_h_d]"ehm^eWbh[WZo^Wl["Wdeijeco$
B[l[be\;l_Z[dY[3?L

Discussion of Evidence

&GGFDUJWF
DPNNVOJDBUJPO
BOE
UFBNXPSL
BNPOH
UIF
JOUFSEJTDJQMJOBSZ
UFBN
JT
FTTFOUJBM
UP
FOBCMF
DMJFOUT

BOE
UIFJS
GBNJMJFT
UP
SFDFJWF
BQQSPQSJBUF
BOE
DPOTJTUFOU
JOGPSNBUJPO
'PS
FYBNQMF
/PUUFS
BOE
#VSOBSE

H ; 9 E C C ; D : 7J ? E D I
(2006)
BOE
.D7FZ
.BEJMM
BOE
'JFMEJOH


BEWPDBUF
GPSNBM
DPVOTFMMJOH
PS
QTZDIPMPHJDBM
TVQQPSU
QSJPS

UP
PS
BGUFS
TVSHFSZ
5TFOH
FU
BM


SFDPNNFOE
POHPJOH
DPOTVMUBUJPO
XJUI
NFNCFST
PG
UIF
NFEJDBM

PODPMPHZ
UFBN
XIFO
DMJFOUT
XJUI
TUPNBT
VOEFSHP
BEEJUJPOBM
USFBUNFOU
GPS
NBMJHOBOU
UVNPVST
TVDI
BT

DIFNPUIFSBQZ
PS
SBEJBUJPO
UIFSBQZ
(SBZ
$PMXFMM
BOE
(PMECFSH
(2005) SFDPNNFOE
SFGFSSJOH
QBUJFOUT

XJUI
QFSJTUPNBM
IFSOJB
UP
B
TVSHFPO
UP
FWBMVBUF
UIF
GFBTJCJMJUZ
PG
TVSHJDBM
SFQBJS

RECOMMENDATION 4
:[i_]dWckjkWbboWYY[fjWXb[fbWde\YWh[X[jm[[dj^[Yb_[dj%\Wc_boWdZWbb^[Wbj^#YWh[fhel_Z[hi"
m^_Y^efj_c_p[i^[Wbj^WdZi[b\#[\YWYo_deijecocWdW][c[dj$
B[l[be\;l_Z[dY[3???

Discussion of Evidence

*O
B
TZTUFNBUJD
SFWJFX
CZ
#SPXO
BOE
3BOEMF
(2005)
UIFSF
XBT
FWJEFODF
CFUXFFO
DMJFOU
JOWPMWFNFOU
JO
UIF

EFDJTJPONBLJOH
QSPDFTT
BOE
B
GBTUFS
QIZTJDBM
SFDPWFSZ
EVF
UP
QFSDFJWFE
DPOUSPM
*OGPSNBUJPO
QPTJUJWF

GFFECBDL
BOE
TVQQPSU
CZ
UIF
OVSTF
IFMQT
UP
EFWFMPQ
TFMGDPOEFODF
UIVT
BMMPXJOH
UIF
DMJFOU
UP
CFDPNF

FOHBHFE
JO
UIFJS
DBSF
(Brown & Randle, 2005)
1JXPOLB
BOE
.FSJOP
(1999)
GPVOE
UIBU
TFMGDBSF
JT
UIF
NPTU

JNQPSUBOU
WBSJBCMF
QSFEJDUJOH
QPTJUJWF
BEKVTUNFOU
JO
CPUI
NBMFT
BOE
GFNBMFT

5IF
DMJFOU
BOE
UIF
OVSTF
TIPVME
EFWFMPQ
B
QMBO
PG
DBSF
UIBU
XJMM
IBWF
BUUBJOBCMF
HPBMT
BOE
XIJDI
DBO
CF
BE
KVTUFE
EFQFOEFOU
PO
UIF
OFFET
PG
UIF
DMJFOU
#SPXO

3BOEMF


/VSTFT
OFFE
UP
QSPNPUF
BOE
XPSL

UPXBSET
TFMGJOEFQFOEFODF
GPS
UIF
DMJFOU
(Ma et al., 2007)
"MMPXJOH
JNNFEJBUF
GBNJMZ
NFNCFST
UP
CFDPNF

JOWPMWFE
XJUI
UIF
BDUJPO
QMBO
GBDJMJUBUFT
UIF
DMJFOUT
BEKVTUNFOU
UP
BO
PTUPNZ
(Brown & Randle, 2005; Pittman
et al., 2008; Piwonka & Merino, 1999)

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  25
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Practice Recommendations:
Pre-Operative Phase
RECOMMENDATION 5
Fh[#ef[hWj_l[[ZkYWj_edi^ekbZX[fhel_Z[ZjeWbbYb_[djiWdZ\Wc_b_[ih[gk_h_d]eijecoikh][ho$
B[l[be\;l_Z[dY[3?X

Discussion of Evidence
H ; 9 E C C ; D : 7J ? E D I

%VF
UP
DIBOHFT
JO
TVSHJDBM
UFDIOJRVF
BOE
TIPSUFS
IPTQJUBM
TUBZT
$PMXFMM
BOE
(SBZ
(2007)
BSHVF
UIBU
QSF
PQFSBUJWF
UFBDIJOH
JT
FTTFOUJBM
JG
DMJFOUT
BSF
UP
QFSGPSN
FWFO
TJNQMF
PTUPNZ
NBOBHFNFOU
UBTLT
TVDI
BT

FNQUZJOH
BOE
DIBOHJOH
B
QPVDI
GPMMPXJOH
IPTQJUBM
EJTDIBSHF
*ODSFBTJOHMZ
CSJFG
IPTQJUBM
TUBZT
SFTUSJDU

UFBDIJOH
UJNF
BOE
NPTU
JNQPSUBOUMZ
MJNJU
UIF
UJNF
BMMPXFE
GPS
UIF
DMJFOU
BOE
GBNJMZ
UP
BTTJNJMBUF
LOPXM
FEHF
BOE
QTZDIPNPUPS
TLJMMT
SFRVJSFE
GPS
TVDDFTTGVM
PTUPNZ
NBOBHFNFOU

$PMXFMM
BOE
(SBZ
(2007)
TZTUFNBUJDBMMZ
SFWJFXFE
UIF
MJUFSBUVSF
BOE
JEFOUJFE
B
TJOHMF
SBOEPNJ[FE
DMJOJDBM

USJBM
B
DPNQBSJTPO
DPIPSU
TUVEZ
HSPVQ
BTTJHONFOU
NFUIPE
OPU
TQFDJFE

BOE
B
DSPTTTFDUJPOBM
TUVEZ
UIBU

FWBMVBUFE
UIF
FGDBDZ
PG
QSFPQFSBUJWF
FEVDBUJPO
#BTFE
PO
OEJOHT
GSPN
UIFTF
TUVEJFT
UIFZ
DPODMVEFE
UIBU

MJNJUFE
FWJEFODF
FYJTUT
TVHHFTUJOH
UIBU
QSFPQFSBUJWF
FEVDBUJPO
CZ
BO
&5/
JNQSPWFT
IFBMUI
SFMBUFE
20-

BOE
TLJMM
BDRVJTJUJPO
EVSJOH
UIF
JNNFEJBUF
QPTUPQFSBUJWF
QFSJPE
BOE
MPOHUFSN
BEKVTUNFOU
UP
BO
PTUPNZ

$IBVEVSJ
FU
BM
(2005)
DPNQBSFE
B
TUSVDUVSFE
QSPHSBN
PG
QSFPQFSBUJWF
FEVDBUJPO
EFMJWFSFE
JO
B
DPNNV
OJUZ
TFUUJOH
UP
B
USBEJUJPOBM
QPTUPQFSBUJWF
QSPHSBN
EFMJWFSFE
EVSJOH
UIF
JNNFEJBUF
QPTUPQFSBUJWF
QFSJPE

JO
BO
BDVUF
DBSF
TFUUJOH
JO
B
SBOEPNJ[FE
DMJOJDBM
USJBM
JOWPMWJOH

TVCKFDUT
VOEFSHPJOH
DPMPTUPNZ
PS

JMFPTUPNZ
GPS
NBOBHFNFOU
PG
DPMPSFDUBM
DBODFS
8IFO
PVUDPNFT
XFSF
NFBTVSFE
TJY
XFFLT
MBUFS
TVCKFDUT

SBOEPNJ[FE
UP
UIF
QSFPQFSBUJWF
UFBDIJOH
JOUFSWFOUJPO
IBE
TJHOJDBOUMZ
HSFBUFS
QSPDJFODZ
JO
UJNF
SF
RVJSFE
GPS
QPVDI
DIBOHFT
TIPSUFS
QPTUPQFSBUJWF
IPTQJUBM
TUBZT
BOE
GFXFS
VOQMBOOFE
IPTQJUBM
BENJTTJPOT

BT
DPNQBSFE
UP
TVCKFDUT
SFDFJWJOH
USBEJUJPOBM
QPTUPQFSBUJWF
UFBDIJOH

)BVHFO
#MJTT
BOE
4BWJL
(2006)
SFQPSUFE
PO
OEJOHT
GSPN
UIF
0TUPNZ
"EKVTUNFOU
4DBMF
0"4

B
WBMJ
EBUFE
JOTUSVNFOU
UIBU
NFBTVSFT
MPOHUFSN
BEKVTUNFOU
JO
B
HSPVQ
PG

SFTQPOEFOUT
XJUI
QFSNBOFOU

TUPNBT
.VMUJWBSJBUF
BOBMZTJT
SFWFBMFE
UIBU
QSFPQFSBUJWF
UFBDIJOH
CZ
BO
&5/
XBT
BTTPDJBUFE
XJUI
IJHIFS

TDPSFT
PO
UIF
0"4
JOEJDBUJOH
QPTJUJWF
BEKVTUNFOU
UP
MJGF
XJUI
BO
PTUPNZ
0MFKOJL
FU
BM
(2005)
SFQPSUFE

UIBU
QBSFOUT
XIP
JOJUJBMMZ
SFQPSUFE
EJGDVMUZ
BEKVTUJOH
UP
UIFJS
DIJMET
PTUPNZ
TUBUFE
UIBU
JOGPSNBUJPO

QSPWJEFE
CZ
UIF
OVSTF
XBT
NPSF
MJLFMZ
UP
CF
QFSDFJWFE
BT
VOEFSTUBOEBCMF
BOE
VTFGVM
UIBO
JOGPSNBUJPO

QSPWJEFE
CZ
UIF
TVSHFPO

5IFTF
OEJOHT
QSPWJEF
FWJEFODF
UIBU
QSFPQFSBUJWF
UFBDIJOH
QSPNPUFT
UIF
TIPSUUFSN
TLJMM
BDRVJTJUJPO
OFFE
FE
UP
NBOBHF
BO
PTUPNZ
BOE
JU
TVHHFTUT
UIBU
UIJT
CFOFU
FYFSUT
B
QPTJUJWF
FGGFDU
PO
MPOHUFSN
BEKVTUNFOU
UP

B
QFSNBOFOU
TUPNB
4FF
"QQFOEJY
&
GPS
B
4BNQMF
0TUPNZ
5FBDIJOH
3FDPSE
QSF
BOE
QPTUTVSHFSZ

26 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

RECOMMENDATION 6
IjecWi_j[cWha_d]i^ekbZX[f[h\ehc[ZedWbbYb_[djikdZ[h]e_d]eijecoikh][ho$
B[l[be\;l_Z[dY[3??W

Discussion of Evidence

$PMXFMM
BOE
(SBZ
(2007)
TZTUFNBUJDBMMZ
SFWJFXFE
UIF
MJUFSBUVSF
BOE
JEFOUJFE
UISFF
TUVEJFT
UIBU
DPNQBSFE

QPTUPQFSBUJWF
PVUDPNFT
JO
DMJFOUT
XIP
SFDFJWFE
QSFPQFSBUJWF
TUPNB
TJUF
NBSLJOH
UP
DMJFOUT
XIP
EJE
OPU

VOEFSHP
TJUF
NBSLJOH
0OF
XBT
B
OPOSBOEPNJ[FE
DPNQBSJTPO
DPIPSU
HSPVQ
BOE
UXP
XFSF
SFUSPTQFDUJWF

H ; 9 E C C ; D : 7J ? E D I
SFWJFXT
1BSL
FU
BM
(1999)
SFUSPTQFDUJWFMZ
SFWJFXFE
TUPNB
DPNQMJDBUJPOT
JO
 
DMJFOUT
XJUI
JOUFTUJOBM

TUPNBT
-PHJTUJD
SFHSFTTJPO
BOBMZTJT
SFWFBMFE
UIBU
QSFPQFSBUJWF
TUPNB
TJUF
NBSLJOH
SFEVDFE
UIF
MJLFMJ
IPPE
PG
QPTUPQFSBUJWF
PTUPNZ
DPNQMJDBUJPOT
4UPNB
TJUF
NBSLJOH
JT
KPJOUMZ
SFDPNNFOEFE
CZ
UIF
"NFSJ
DBO
4PDJFUZ
PG
$PMPSFDUBM
4VSHFPOT
BOE
UIF
8PVOE
0TUPNZ
$POUJOFODF
/VSTFT
4PDJFUZ
(2007)

4UPNB
TJUF
NBSLJOH
TIPVME
CF
QFSGPSNFE
CZ
BO
&5/
PS
B
IFBMUIDBSF
QSPGFTTJPOBM
XIP
IBT
CFFO
USBJOFE

JO
UIF
QSJODJQMFT
PG
TUPNB
TJUF
NBSLJOH
BOE
JT
BXBSF
PG
UIF
JNQMJDBUJPOT
PG
PTUPNZ
DBSF
BOE
QPPS
TUPNB

TJUF
NBSLJOH
'PS
UIF
QFEJBUSJD
QBUJFOU
NBOZ
TUPNBT
BSF
DSFBUFE
XJUIJO
UIF
STU
IPVST
PG
MJGF
BOE
BSF
EPOF

JO
BO
FNFSHFODZ
TFUUJOH
TP
UIFZ
NBZ
OPU
CF
TJUFE
QSJPS
UP
TVSHFSZ

"MUIPVHI
FWJEFODF
JT
MJNJUFE
FYJTUJOH
SFTFBSDI
TUSPOHMZ
TVHHFTUT
UIBU
TUPNB
TJUF
NBSLJOH
CZ
BO
&5/
PS

IFBMUIDBSF
QSPGFTTJPOBM
USBJOFE
JO
QSJODJQMFT
PG
UIJT
QSPDFEVSF
SFEVDFT
TUPNBM
BOE
QFSJTUPNBM
DPNQMJ
DBUJPOT
5IJT
FWJEFODF
JT
BVHNFOUFE
CZ
UIF
DMJOJDBM
FYQFSJFODF
PG
TVSHFPOT
BOE
&5/T
SFTVMUJOH
JO
UIF

KPJOU
SFDPNNFOEBUJPO
QSPNVMHBUFE
CZ
UIF
80$/
4PDJFUZ
BOE
"NFSJDBO
4PDJFUZ
PG
$PMPSFDUBM
4VSHFPOT

5IFSFGPSF
BMM
DMJFOUT
VOEFSHPJOH
FMFDUJWF
TVSHFSZ
FYQFDUFE
UP
SFTVMU
JO
TUPNB
DSFBUJPO
TIPVME
VOEFSHP

TUPNB
TJUF
NBSLJOH

RECOMMENDATION 7
;nfbeh[j^[fej[dj_Wb_cfWYje\eijecoikh][hoed_dj_cWYoWdZi[nkWb\kdYj_ed_d]m_j^Yb_[dj%fWhjd[h$
B[l[be\;l_Z[dY[3'W

Discussion of Evidence

6OEFSHPJOH
PTUPNZ
TVSHFSZ
XIFUIFS
UIF
PTUPNZ
JT
UFNQPSBSZ
PS
QFSNBOFOU
DBO
IBWF
B
QSPGPVOE
JN

QBDU
PO
JOUJNBDZ
BOE
TFYVBMJUZ
"MUIPVHI
TFYVBM
GVODUJPO
NBZ
CF
BMUFSFE
TFYVBMJUZ
DBOOPU
CF
EFTUSPZFE

(Junkin & Beitz, 2005)
"MUFSFE
TFYVBM
GVODUJPO
JO
NFO
DBO
SFTVMU
GSPN
EBNBHF
PG
UIF
QSPTUBUJD
OFSWF
QMFYVT

BOE
UIF
BVUPOPNJD
OFSWFT
UIBU
BSF
DMPTF
UP
UIF
SFDUVN
EVSJOH
DPMPSFDUBM
PS
CMBEEFS
DBODFS
TVSHFSZ
SF
TVMUJOH
JO
TFOTPSZ
MPTT
BOE
FSFDUJMF
GBJMVSF
*O
XPNFO
UIFSF
NBZ
CF
OFSWF
WBTDVMBS
BOE
UJTTVF
EBNBHF

SFTVMUJOH
JO
EZTQBSFVOJB
EBNBHF
UP
UIF
WBHJOB
BMUFSFE
WBHJOBM
MVCSJDBUJPO
QSPCMFNT
XJUI
FOHPSHFNFOU

SFEVDFE
WBHJOBM
TQBDF
BOE
QPTTJCMF
QSPMBQTF
PG
UIF
WBHJOBM
XBMM
PS
CMBEEFS
(Black, 2004)

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  27
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

*O
B
TZTUFNBUJD
SFWJFX
DPOEVDUFE
CZ
#SPXO
BOE
3BOEMF
(2005)
JU
XBT
GPVOE
UIBU
QBUJFOUT
XPSSZ
BCPVU
TFY
VBM
JTTVFT
UIFZ
GFFM
MFTT
TFYVBMMZ
BUUSBDUJWF
BOE
SFQPSU
QSPCMFNT
XJUI
UIFJS
TFY
MJWFT
JODMVEJOH
JNQPUFODZ

BOE
MPTT
PG
FSFDUJMF
GVODUJPO
GPS
NFO
BOE
EZTQBSFVOJB
WBHJOBM
ESZOFTT
BOE
MPTT
PG
EFTJSF
BNPOH
XPNFO

,JMJD
FU
BM
(2007)
FYBNJOFE
UIF
FGGFDU
PO
TFYVBM
GVODUJPO
EVF
UP
B
QFSNBOFOU
PTUPNZ
SFTVMUJOH
GSPN
B
HBT
USPJOUFTUJOBM
NBMJHOBODZ
PS
JOBNNBUPSZ
CPXFM
EJTFBTF
PO

JOEJWJEVBMT
DPNQBSJOH
UIFJS
FYQFSJFODFT

XJUI

DPOUSPMT
OP
PTUPNZ

6TJOH
UIF
(PMPNCPL3VTU
*OWFOUPSZ
PG
4FYVBM
4BUJTGBDUJPO
XPNFO
IBE
B

IJHIFS
SBUF
PG
TFYVBM
EZTGVODUJPO
DPNQBSFE
UP
NFO
7BHJOJTNVT
BOE
BOPSHBTNJB
TDPSFT
XFSF
IJHIFS
JO

UIF
DPMPTUPNZ
HSPVQ
DPNQBSFE
UP
UIPTF
XJUI
BO
JMFPTUPNZ
XIJDI
XBT
TUBUJTUJDBMMZ
TJHOJDBOU
*NQPUFODF

EFDSFBTFE
PWFS
UJNF
TFYVBM
EZTGVODUJPO
XBT
TJHOJDBOUMZ
NPSF
QSPOPVODFE
JO
UIF
PTUPNZ
HSPVQ
DPN
QBSFE
UP
UIF
DPOUSPM
HSPVQ
BOE
UIPTF
XJUI
B
CFUUFS
CPEZ
JNBHF
IBE
CFUUFS
TFYVBM
GVODUJPOJOH


H ; 9 E C C ; D : 7J ? E D I

*O
B
%BOJTI
TUVEZ
DPNQBSJOH
QBUJFOUT
XJUI
BOE
XJUIPVU
B
TUPNB
BT
B
SFTVMU
PG
DPMPSFDUBM
DBODFS
TVSHFSZ

3PTT
FU
BM (2007)
GPVOE
UIBU
EVSJOH
UIF
UXPZFBS
GPMMPXVQ
JOUFSWJFX
TFYVBM
GVODUJPO
TFYVBM
FOKPZNFOU

BOE
GFNBMF
TFYVBM
QSPCMFNT
XFSF
OPU
TJHOJDBOUMZ
BGGFDUFE
CZ
UIF
QSFTFODF
PG
B
TUPNB
CVU
NBMF
QBUJFOUT

XJUI
B
TUPNB
IBE
TJHOJDBOUMZ
NPSF
TFYVBM
QSPCMFNT
UIBO
OPOTUPNB
QBUJFOUT
4ZNNT
FU
BM
(2008

FYBN
JOFE
UIF
TFYVBM
IFBMUI
BOE
20-
BNPOH
NBMF
WFUFSBOT
XJUI
BOE
XJUIPVU
BO
PTUPNZ
GPMMPXJOH
B
CPXFM
SF
TFDUJPO
VTJOH
B
NPEJFE
$JUZ
PG
)PQF
20-0TUPNZ
2VFTUJPOOBJSF
BOE
GPDVT
HSPVQT
0G
UIF

QBSUJDJ
QBOUT

IBE
BO
PTUPNZ
3FTVMUT
TIPXFE
UIBU

PG
PTUPNBUFT
XIP
XFSF
TFYVBMMZ
BDUJWF
CFGPSF
UIFJS

PTUPNZ
TVSHFSZ
XFSF
JOBDUJWF
QPTUPQFSBUJWFMZ
DPNQBSFE
UP

PG
UIPTF
XJUIPVU
BO
PTUPNZ
"
HSFBUFS

QSPQPSUJPO
PG
PTUPNBUFT
DIBOHFE
GSPN
IBWJOH
OP
FSFDUJMF
QSPCMFNT
UP
IBWJOH
FSFDUJMF
QSPCMFNT
BGUFS

TVSHFSZ
DPNQBSFE
XJUI
DPOUSPMT

WT


5IPTF
XJUI
BO
PTUPNZ
XIP
SFTVNFE
TFYVBM
BDUJWJUZ
BOE

XFSF
TBUJTFE
XJUI
UIFJS
BDUJWJUZ
FOKPZFE
MJGF
NPSF
XFSF
NPSF
TBUJTFE
XJUI
UIFJS
BQQFBSBODF
IBE
MFTT

JOUFSGFSFODF
XJUI
TPDJBM
BDUJWJUJFT
BOE
JTPMBUJPO
MFTT
EJGDVMUZ
BEKVTUJOH
UP
UIF
PTUPNZ
BOE
XJUI
QFSTPOBM

SFMBUJPOTIJQT
BOE
MFTT
JOUFSGFSFODF
XJUI
UIFJS
BCJMJUZ
UP
CF
JOUJNBUF

,SPVTF
FU
BM
(2007

NBJMFE
$JUZ
PG
)PQF
20-
PTUPNZ
RVFTUJPOOBJSFT
UP
JOEJWJEVBMT
XJUI
B
DPMPTUPNZ

EVF
UP
DBODFS
PS
OPODBODFS
TVSHFSZ
0G
UIF

SFTQPOEFOUT
NPTU
PG
XIPN
IBE
DBODFS

UIFSF
XBT
OP

TUBUJTUJDBMMZ
TJHOJDBOU
EJGGFSFODF
GPS
RVFTUJPOT
SFMBUFE
UP
TFYVBM
GVODUJPO
CFUXFFO
CPUI
HSPVQT
3PVHIMZ

IBMG
PG
UIF
QBSUJDJQBOUT
JO
CPUI
HSPVQT
EJE
OPU
IBWF
TFYVBM
SFMBUJPOT
BGUFS
TVSHFSZ
&SFDUJMF
EZTGVODUJPO
PD
DVSSFE
JO

PG
DBODFS
QBUJFOUT
BOE

PG
UIF
OPODBODFS
HSPVQ
$IFOH
(2001

BEBQUFE
B
20-
TDBMF
UP

EFUFSNJOF
XIBU
GBDUPST
NBZ
JOVFODF
20-
PG
UIPTF
XJUI
B
DPMPTUPNZ
JO
)POH
,POH

PG
QBSUJDJQBOUT

TUBUFE
UIFZ
XFSF
OPU
FOHBHJOH
JO
TFYVBM
BDUJWJUZ
EVF
UP
BHF
XPVOE
QBJO
XPSSZ
BCPVU
IVSUJOH
UIFJS
TUPNB

PS
QPTUPQFSBUJWF
JNQPUFODF
/VHFOU
FU
BM
(1999)
TFOU
PVU
B
RVFTUJPOOBJSF
UP
QBUJFOUT
XJUI
BO
PTUPNZ


IBE
B
DPMPTUPNZ

IBE
BO
JMFPTUPNZ


PG
QBUJFOUT
XJUI
B
DPMPTUPNZ
XIP
SFTQPOEFE
IBE
QSPCMFNT

XJUI
UIFJS
TFY
MJWFT
XJUI

CFJOH
JNQPUFOU

XFSF
JNQPUFOU
QSFPQFSBUJWFMZ


PG
QBUJFOUT
XJUI

BO
JMFPTUPNZ
XIP
SFTQPOEFE
IBE
TFYVBM
QSPCMFNT
XJUI

CFJOH
JNQPUFOU
0G

GFNBMFT

TVGGFSFE

GSPN
EZTQBSFVOJB
UXP
IBE
UIJT
QSPCMFN
QSJPS
UP
TVSHFSZ


"MUIPVHI
NPTU
PG
UIF
MJUFSBUVSF
UP
EBUF
GPDVTFT
PO
UIF
JOEJWJEVBM
VOEFSHPJOH
TVSHFSZ
UIFJS
QBSUOFST
DBO

CF
JNQBDUFE
BT
XFMM
1FSTTPO
FU
BM
(2004

FYQMPSFE
TQPVTFT
QFSDFQUJPOT
PG
MJWJOH
XJUI
B
QBSUOFS
EJBHOPTFE

XJUI
SFDUBM
DBODFS
SFTVMUJOH
JO
BO
PTUPNZ
/JOF
TQPVTFT
XFSF
JOUFSWJFXFE
EVSJOH
UXP
GPDVT
HSPVQ
TFT
TJPOT
'JWF
UIFNFT
FNFSHFE
GSPN
UIJT
TUVEZ
POF
PG
XIJDI
JODMVEFE
UIF
BMUFSFE
CPEZ
4QPVTFT
TUBUFE

UIFJS
SFMBUJPOTIJQ
DIBOHFE
UIFZ
SFGSBJOFE
GSPN
JOUJNBUF
DPOUBDU
BOE
TPNF
IBE
EJGDVMUZ
EJTDVTTJOH
BM
UFSFE
TFYVBM
GVODUJPOJOH
XJUI
UIFJS
QBSUOFS

28 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

)FBMUIDBSF
QSPWJEFST
IBWF
BO
PCMJHBUJPO
UP
BEESFTT
TFYVBM
IFBMUI
BOE
JOUJNBDZ
DPODFSOT
XJUI
QBUJFOUT

(Symms et al., 2008)
'PS
OVSTFT
UP
EFMJWFS
IPMJTUJD
DPNQSFIFOTJWF
DBSF
TFYVBMJUZ
BOE
TFYVBM
IFBMUI
DPO
DFSOT
NVTU
CF
JODMVEFE
JO
UIF
QMBO
PG
DBSF
(Junkin & Beitz, 2005)
1FSTTPO
BOE
-BSTTPO
(2005) FYBNJOFE

PTUPNZ
QBUJFOUT
QFSDFQUJPOT
PO
OVNFSPVT
RVBMJUZPGDBSF
JTTVFT
JO
B
QSPTQFDUJWF
EFTDSJQUJWF
TUVEZ
.PTU

PG
UIF
SFTQPOEFOUT
GFMU
UIF
JUFNT
BCPVU
QBSUJDJQBUJPO
XFSF
JNQPSUBOU
IPXFWFS

PG
UIPTF
XJUI
B
DP
MPTUPNZ
BOE

PG
UIPTF
XJUI
BO
JMFPTUPNZ
XFSF
EJTTBUJTFE
XJUI
UIF
PQQPSUVOJUZ
UP
UBML
BCPVU
UIFJS

TFYVBM
MJGF
XJUI
&5/T
4QPVTFT
PG
QBSUOFST
XJUI
BO
PTUPNZ
GPVOE
UIFSF
XBT
B
MBDL
PG
JOGPSNBUJPO
GSPN

DBSFHJWFST
BCPVU
TFYVBM
QSPCMFNT
SFTVMUJOH
GSPN
PTUPNZ
TVSHFSZ
1FSTTPO
FU
BM


,JMJD
FU
BM
(2007)

FYBNJOFE
UIF
FGGFDU
PO
TFYVBM
GVODUJPO
EVF
UP
B
QFSNBOFOU
PTUPNZ
SFTVMUJOH
GSPN
B
HBTUSPJOUFTUJOBM
NB
MJHOBODZ
PS
JOBNNBUPSZ
CPXFM
EJTFBTF
PO

JOEJWJEVBMT
DPNQBSJOH
UIFJS
FYQFSJFODFT
XJUI

DPOUSPMT

OP
PTUPNZ

6TJOH
UIF
(PMPNCPL3VTU
*OWFOUPSZ
PG
4FYVBM
4BUJTGBDUJPO

PG
PTUPNZ
QBUJFOUT
EJE
OPU

H ; 9 E C C ; D : 7J ? E D I
UIJOL
UIFZ
XFSF
BEFRVBUFMZ
JOGPSNFE
BCPVU
TVSHFSZ
BOE
JUT
PVUDPNF

/VSTFT
OFFE
FEVDBUJPO
BCPVU
IPX
UP
BTTFTT
BOE
IBOEMF
RVFTUJPOT
BCPVU
TFYVBMJUZ
JO
PSEFS
UP
QSPWJEF

JOGPSNBUJPO
TVQQPSU
BOE
QSBDUJDBM
BEWJDF
NPSF
FGGFDUJWFMZ
UP
QBUJFOUT
XJUI
BO
PTUPNZ
(Persson et al., 2005;
Symms et al., 2008)
5IFZ
OFFE
UP
VOEFSTUBOE
UIF
UZQF
PG
TVSHFSZ
BOE
UIF
FGGFDU
JU
NBZ
IBWF
PO
QBUJFOUT
UP

LOPX
XIFO
UP
SFGFS
UIF
QBUJFOU
GPS
BEEJUJPOBM
IFMQ
BOE
UP
VOEFSTUBOE
IJTIFS
MJNJUBUJPOT
JO
EJTDVTTJOH

TFYVBM
NBUUFST
(Black, 2004

5IF
1-*44*5
NPEFM
1FSNJTTJPO
-JNJUFE
*OGPSNBUJPO
4QFDJD
4VHHFTUJPO

BOE
*OUFOTJWF
5IFSBQZ

BT
DJUFE
JO
+VOLJO
BOE
#FJU[
(2005)
JT
B
GSBNFXPSL
GPS
OVSTFT
BOE
PUIFS
IFBMUI
DBSF
QSPWJEFST
UP
GPMMPX
XIFO
BTTFTTJOH
BOE
EFUFSNJOJOH
JOUFSWFOUJPOT
SFMBUFE
UP
TFYVBM
IFBMUI
(JWJOH

QFSNJTTJPO
GPS
UIF
DMJFOUQBSUOFS
UP
EJTDVTT
JOUJNBDZ
BOE
TFYVBMJUZ
JT
DSJUJDBM
1SPWJEJOH
JOGPSNBUJPO
BOE

TQFDJD
TVHHFTUJPOT
PO
IPX
UP
BEESFTT
PS
EFBM
XJUI
DMJFOUTQFDJD
DPODFSOT
JT
XJUIJO
UIF
OVSTFT
TDPQF
PG

QSBDUJDF
QSPWJEFE
UIFZ
IBWF
B
TPMJE
LOPXMFEHF
CBTF
BOE
DPNGPSU
MFWFM
UP
EFBM
XJUI
DMJFOU
TQFDJD
DPODFSOT

5IPTF
DMJFOUT
SFRVJSJOH
NPSF
IFMQ
JOUFOTJWF
UIFSBQZ

TIPVME
CF
SFGFSSFE
UP
PUIFS
IFBMUIDBSF
QSPGFTTJPO
BMT
QTZDIPUIFSBQJTU
TFYVBM
IFBMUI
DMJOJD

*O
B
TUVEZ
FYBNJOJOH
UIF
JNQBDU
PG
IPNF
WJTJUT
EVSJOH
B
TJY
NPOUI
QFSJPE
QBUJFOUT
XFSF
GPMMPXFE
NPOUIMZ
FYQFSJNFOUBM
HSPVQ

PS
BU
UISFF
BOE
TJY
NPOUIT
DPOUSPM

HSPVQ

5IFSF
XBT
OP
EFDSFBTF
JO
TFYVBM
QSPCMFNT
CFUXFFO
CPUI
HSPVQT
(Addis, 2003

*U
XBT
IZQPUIFTJ[FE

UIBU
UIJT
MBDL
PG
TVDDFTT
NBZ
IBWF
SFTVMUFE
GSPN
EJGDVMUZ
EJTDVTTJOH
TFYVBM
NBUUFST
JO
B
5VSLJTI
TPDJFUZ

BOEPS
UIF
SFTFBSDIFS
XBT
VOBCMF
UP
QSPWJEF
TQFDJD
BEWJDF
SFMBUFE
UP
TFYVBM
EJGDVMUJFT

0TUPNZ
TVSHFSZ
DBO
TJHOJDBOUMZ
BGGFDU
TFYVBM
GVODUJPO
UIFSFCZ
JNQBDUJOH
JOUJNBDZ
BOE
TFYVBM
SFMBUJPO
TIJQT
OPU
POMZ
GPS
UIF
DMJFOU
CVU
GPS
UIFJS
QBSUOFS
BT
XFMM
5IF
PQQPSUVOJUZ
UP
MJTUFO
TVQQPSU
BOE
FODPVS
BHF
PQFO
EJBMPHVF
XJUI
DMJFOUT
BOE
UIFJS
QBSUOFS
JT
DSJUJDBM
4FF
"QQFOEJY
'
GPS
BEEJUJPOBM
UJQT
PO
JOUJNBDZ

BOE
TFYVBMJUZ

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  29
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

RECOMMENDATION 8
Fhe]h[ii_l[CkiYb[H[bWnWj_edJhW_d_d]FCHJi^ekbZX[e\\[h[ZjeYb_[djikdZ[h]e_d]eijeco
ikh][hoWifWhje\hekj_d[YWh[$
B[l[be\;l_Z[dY[3?X

Discussion of Evidence

1.35
JT
B
CFIBWJPVSBM
UFDIOJRVF
CBTFE
PO
QSPHSFTTJWF
SFMBYBUJPO
PG

NBKPS
NVTDMF
HSPVQT
BOE
DPO
USPMMFE
CSFBUIJOH
$IFVOH
.PMBTTJPUJT
BOE
$IBOH
(2003)
DPNQBSFE
BOYJFUZ
MFWFMT
BOE
IFBMUISFMBUFE
20-

H ; 9 E C C ; D : 7J ? E D I

JO
B
SBOEPNJ[FE
DMJOJDBM
USJBM
PG

TVCKFDUT
4VCKFDUT
SBOEPNJ[FE
UP
UIF
DPOUSPM
HSPVQ
SFDFJWFE
USBEJUJPOBM

DBSF
GPMMPXJOH
PTUPNZ
TVSHFSZ
BOE
UIPTF
SBOEPNJ[FE
UP
UIF
FYQFSJNFOUBM
HSPVQ
SFDFJWFE
USBEJUJPOBM
DBSF

QMVT
1.35
CFHVO
QPTUPQFSBUJWFMZ
PO
EBZ
WF
4VCKFDUT
SBOEPNJ[FE
UP
1.35
IBE
TJHOJDBOUMZ
MPXFS
TUBUF
BOYJFUZ
TDPSFT
BOE
TJHOJDBOUMZ
IJHIFS
20-
TDPSFT
PO
B
HFOFSJD
20-
JOTUSVNFOU
BGUFS

XFFLT
/P

EJGGFSFODFT
XFSF
GPVOE
XIFO
HSPVQT
XFSF
DPNQBSFE
VTJOH
B
DPOEJUJPOTQFDJD
20-
JOTUSVNFOU
/P
BE
WFSTF
TJEF
FGGFDUT
XFSF
SFQPSUFE
5IFTF
OEJOHT
TVQQPSU
SPVUJOF
1.35
GPS
DMJFOUT
VOEFSHPJOH
PTUPNZ
TVS
HFSZ
CFHJOOJOH
QPTUPQFSBUJWFMZ
PO
EBZ
WF
BT
B
NFBOT
PG
JNQSPWJOH
20-
BOE
SFEVDJOH
BOYJFUZ
EVSJOH

UIF
FBSMZ
QPTUPQFSBUJWF
QIBTF
GPMMPXJOH
DSFBUJPO
PG
BO
PTUPNZ
"EEJUJPOBM
SFTFBSDI
BCPVU
UIJT
BOE
PUIFS

CFIBWJPVSBMCBTFE
JOUFSWFOUJPOT
GPS
JNQSPWJOH
20-
BOE
SFEVDJOH
BOYJFUZ
JO
UIJT
QPQVMBUJPO
JT
OFFEFE

Practice Recommendations:
Post-Operative Phase
RECOMMENDATION 9
7ii[iij^[ijecW_cc[Z_Wj[bofeij#ef[hWj_l[boWdZj^[ijecW%f[h_ijecWbia_dYedZ_j_edm_j^[WY^
Wffb_WdY[Y^Wd][ki_d]WlWb_ZWj[ZYbWii_YWj_edjeebjeced_jeh\ehYecfb_YWj_edi$
B[l[be\;l_Z[dY[3?L

Discussion of Evidence

5IF
TUPNB
BOE
QFSJTUPNBM
TLJO
OFFE
UP
CF
BTTFTTFE
EVSJOH
UIF
JNNFEJBUF
QPTUPQFSBUJWF
QFSJPE
TFF
"Q
QFOEJY
(
GPS
B
4BNQMF
"TTFTTNFOU
'PSN

5IJT
BTTFTTNFOU
JT
VTFE
UP
NPOJUPS
QSPHSFTT
UPXBSE
IFBMJOH

BOE
GPS
GVUVSF
DPNQBSJTPO
TIPVME
DPNQMJDBUJPOT
EFWFMPQ

*O
B
TZTUFNBUJD
MJUFSBUVSF
SFWJFX
4BMWBEBMFOB
(2008)
QPJOUT
PVU
JODPOTJTUFODJFT
JO
PQFSBUJPOBM
EFOJUJPOT

PG
DPNQMJDBUJPOT
JOBEFRVBUF
SFQPSUJOH
PG
TVCKFDU
BUUSJUJPO
BOE
NJTTJOH
EBUB
XIFO
SFQPSUJOH
UIF
JODJEFODF

PG
DPNQMJDBUJPOT
SFTVMUJOH
JO
HBQT
JO
PVS
LOPXMFEHF
PG
UIF
QSFWBMFODF
BOE
JODJEFODF
PG
PTUPNZSFMBUFE

DPNQMJDBUJPOT
BOE
HBQT
JO
PVS
LOPXMFEHF
PG
SJTL
BOE
QSPUFDUJWF
GBDUPST
$PMXFMM
BOE
#FJU[
(2007

SFQPSUFE

B
DPOUFOU
WBMJEBUJPO
TUVEZ
PG
EFOJUJPOT
GPS
DPNQMJDBUJPOT
BTTPDJBUFE
XJUI
PTUPNJFT
CBTFE
PO
UIF
SFTQPOT
FT
PG

XPVOE
PTUPNZ
BOE
DPOUJOFODF
OVSTFT
$PNQMJDBUJPOT
XFSF
EJWJEFE
JOUP
UXP
CSPBE
DBUFHPSJFT


TUPNBM
BOE
QFSJTUPNBM
DPNQMJDBUJPOT
4UPNBM
DPNQMJDBUJPOT
BGGFDU
UIF
PTUPNZ
JUTFMG
BOE
QFSJTUPNBM

30 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

DPNQMJDBUJPOT
BGGFDU
UIF
TLJO
JNNFEJBUFMZ
TVSSPVOEJOH
UIF
TUPNB
4UPNBM
DPNQMJDBUJPO
EFOJUJPOT
WBMJ
EBUFE
JO
UIJT
TUVEZ
XFSF


QBSBTUPNBM
IFSOJB


QSPMBQTF


OFDSPTJT


NVDPDVUBOFPVT
TFQBSBUJPO


SF
USBDUJPO


TUFOPTJT


TUVMB
BOE


USBVNB
1FSJTUPNBM
DPNQMJDBUJPO
EFOJUJPOT
WBMJEBUFE
JO
UIJT
TUVEZ

XFSF


WBSJDFT


DBOEJEJBTJT


GPMMJDVMJUJT


NVDPTBM
USBOTQMBOUBUJPO


QTFVEPWFSSVDPVT
MFTJPOT



QZPEFSNB
HBOHSFOPTVN


TVUVSF
HSBOVMPNBT


JSSJUBOU
DPOUBDU
EFSNBUJUJT
BOE


USBVNB

5IF
TZTUFNBUJD
MJUFSBUVSF
SFWJFX
TVQQPSUJOH
UIJT
CFTU
QSBDUJDF
HVJEFMJOF
BMTP
VODPWFSFE
WBSJBCJMJUZ
JO
PQ
FSBUJPOBM
EFOJUJPOT
PG
TUPNBM
BOE
QFSJTUPNBM
DPNQMJDBUJPOT
*O
BEEJUJPO
BWBJMBCMF
SFTFBSDI
XBT
MJNJUFE

UP
TFWFSBM
PG
UIF
NPSF
DPNNPO
BOE
QSPCMFNBUJD
TUPNBM
DPNQMJDBUJPOT
SFUSBDUJPO
QFSJTUPNBM
IFSOJB

QSPMBQTF
BOE
OFDSPTJT
1FSJTUPNBM
TLJO
QSPCMFNT
UFOEFE
UP
CF
MVNQFE
JOUP
B
TJOHMF
DBUFHPSZ
%FOJUJPOT

GPS
UIFTF
DPNNPO
TUPNBM
DPNQMJDBUJPOT
BSF
QSPWJEFE
JO
5BCMF

4PNF
PG
UIF
TUVEJFT
SFWJFXFE
FWBMVBUFE

H ; 9 E C C ; D : 7J ? E D I
QSPCMFNT
BTTPDJBUFE
XJUI
DPQJOH
BOE
BEBQUBUJPO
UP
BO
PTUPNZ
8IJMF
QTZDIPTPDJBM
BEKVTUNFOU
JT
B
DFOUSBM

DPODFSO
UP
OVSTFT
DBSJOH
GPS
DMJFOUT
XJUI
PTUPNJFT
UIFTF
JTTVFT
BSF
EJTDVTTFE
JO
3FDPNNFOEBUJPO


Table 9-1: Definitions of Common Stomal and Peristomal Complications

Complication Definition

Retraction
%JTBQQFBSBODF
PG
OPSNBM
TUPNBM
QSPUSVTJPO
JO
MJOF
XJUI
PS
CFMPX
TLJO
MFWFM

Peristomal Hernia
%FGFDU
JO
UIF
BCEPNJOBM
GBTDJB
BMMPXJOH
UIF
HVU
UP
CVMHF
JOUP
UIF
QBSBTUPNBM
BSFB

Prolapse
5FMFTDPQJOH
PG
UIF
CPXFM
UISPVHI
UIF
TUPNB

Necrosis
%FBUI
PG
TUPNBM
UJTTVF
XJUI
JNQBJSFE
MPDBM
CMPPE
PX

Peristomal
0OF
PG
B
WBSJFUZ
PG
EFSNBUPTFT
BGGFDUJOH
UIF
TLJO
JNNFEJBUFMZ
TVSSPVOEJOH
UIF

Skin Problems TUPNB
DPNNPO
NBOJGFTUBUJPOT
JODMVEF
JSSJUBOU
EFSNBUJUJT
BMMFSHJD
EFSNBUJUJT

DBOEJEJBTJT
GPMMJDVMJUJT
PS
USBVNB

Modified from Colwell and Beitz (2007)

"
OVNCFS
PG
TUVEJFT
EPDVNFOU
UIF
QSFTFODF
PG
DMJOJDBMMZ
SFMFWBOU
TUPNBM
BOE
QFSJTUPNBM
DPNQMJDBUJPOT

PDDVSSJOH
EVSJOH
UIF
FBSMZ
QPTUPQFSBUJWF
QFSJPE
PS
NPOUIT
UP
ZFBST
MBUFS
4BMWBEBMFOB
(2008)
TZTUFNBUJDBMMZ

SFWJFXFE
UIF
MJUFSBUVSF
BOE
JEFOUJFE

TUVEJFT
UIBU
NFBTVSFE
UIF
JODJEFODF
PG
TUPNBM
BOE
QFSJTUPNBM

DPNQMJDBUJPOT
GPMMPXJOH
PTUPNZ
TVSHFSZ
JODMVEJOH
FJHIU
SBOEPNJ[FE
DMJOJDBM
USJBMT
0WFSBMM
DPNQMJDBUJPO

SBUFT
XFSF

UP

5IF
NPTU
DPNNPO
DPNQMJDBUJPOT
XFSF
TUPNBM
SFUSBDUJPO
QFSJTUPNBM
IFSOJB
QSP
MBQTF
OFDSPTJT
BOE
QFSJTUPNBM
TLJO
QSPCMFNT
5BCMF



 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  31
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Table 9-2: Incidence of Stomal and Peristomal Complications at 3 and 12 months

Complication Incidence at 3 months Incidence at 12 months

Retraction



Peristomal Hernia



Prolapse



Necrosis


H ; 9 E C C ; D : 7J ? E D I

Peristomal skin problems



Modified from Salvadalena, (2008)

)FSMVGTFO
FU
BM
(2006)
SFQPSUFE
B
DSPTT
TFDUJPOBM
TUVEZ
PG

QFSTPOT
XJUI
QFSNBOFOU
JMFPTUPNJFT

DPMPTUPNJFT
BOE
VSPTUPNJFT
$PNQMJDBUJPOT
PDDVSSFE
JO

BOE
XFSF
DMBTTJFE
BT
NJME


NPEFS
BUF


PS
TFWFSF


5ZQFT
PG
TLJO
EBNBHF
JODMVEFE
FSPTJPO
NBDFSBUJPO
FSZUIFNB
BOE
JSSJUBOU

EFSNBUJUJT
$PMMFDUJWFMZ
UIFTF
BDDPVOUFE
GPS

PG
BMM
DPNQMJDBUJPOT
1FSJTUPNBM
TLJO
EJTPSEFST
QFSTJTUFE

GPS
NPSF
UIBO
UISFF
NPOUIT
JO

PG
DBTFT
CVU

EJE
OPU
TFFL
QSPGFTTJPOBM
DBSF
$MJFOUT
XJUI
BO

JMFPTUPNZ
IBE
UIF
IJHIFTU
DPNQMJDBUJPO
SBUF


GPMMPXFE
CZ
VSPTUPNZ


BOE
DPMPTUPNZ



3FTFBSDI
GPDVTJOH
PO
UIF
JODJEFODF
PS
QSFWBMFODF
PG
TUPNBM
PS
QFSJTUPNBM
DPNQMJDBUJPOT
BNPOH
OFPOBUFT

PG
DIJMESFO
XBT
WFSZ
TQBSTF
%VDIFTOF
FU
BM
(2002

SFQPSUFE
PO
DPNQMJDBUJPOT
PG
FJHIU
OFPOBUFT
XIP
VO
EFSXFOU
PTUPNZ
TVSHFSZ
GPS
OFDSPUJ[JOH
FOUFSPDPMJUJT
O

PS
JNQFSGPSBUF
BOVT
O

5IF
PWFSBMM
DPN
QMJDBUJPO
SBUF
GPS
UIJT
TNBMM
HSPVQ
XBT

1BSL
FU
BM (1999)
BMTP
NFOUJPOT
JODMVTJPO
PG
OFPOBUFT
JO
UIFJS

SFUSPTQFDUJWF
SFWJFX
PG
 
TVCKFDUT
CVU
DPNQMJDBUJPO
SBUFT
BSF
SFQPSUFE
JO
BHHSFHBUF
GPSN
POMZ

$PMMFDUJWFMZ
UIJT
FWJEFODF
EFNPOTUSBUFT
UIBU
TUPNB
BOE
QFSJTUPNBM
DPNQMJDBUJPOT
BSF
DPNNPO
BOE
BG
GFDU
BMM
UZQFT
PG
PTUPNJFT
5IF
QSFWBMFODF
BOE
BEWFSTF
DPOTFRVFODFT
BTTPDJBUFE
XJUI
UIFTF
DPNQMJDBUJPOT

SFJOGPSDFT
UIF
OFFE
GPS
BTTFTTNFOU
PG
UIF
TUPNB
BOE
QFSJTUPNBM
TLJO
CPUI
EVSJOH
UIF
JNNFEJBUF
QPTU
PQFSBUJWF
QFSJPE
BOE
BU
MFBTU
POF
ZFBS
GPMMPXJOH
TUPNB
TVSHFSZ
"MUIPVHI
UIFSF
JT
JOTVGDJFOU
FWJEFODF

UP
TVQQPSU
UIFJS
VTF
FYQFSU
PQJOJPO
DPODVST
UIBU
UIF
VTF
PG
B
TUBOEBSEJ[FE
BTTFTTNFOU
UPPM
FOIBODFT

EJBHOPTUJD
BDDVSBDZ
XIJDI
JO
UVSO
EJSFDUT
USFBUNFOU
5IFSF
JT
B
OFFE
UP
EFWFMPQ
BOE
WBMJEBUF
TUBOEBSE
J[FE
DMBTTJDBUJPO
UPPMT

32 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

RECOMMENDATION 10
?Z[dj_\oh_ia\WYjehij^Wj_dk[dY[ijecWbWdZf[h_ijecWbYecfb_YWj_edi$
B[l[be\;l_Z[dY[3???

Discussion of Evidence

3FTFBSDI
SFWFBMT
NVMUJQMF
GBDUPST
BTTPDJBUFE
XJUI
BO
JODSFBTFE
JODJEFODF
PG
TUPNBM
PS
QFSJTUPNBM
DPN
QMJDBUJPOT
"MUIPVHI
UIFSF
JT
JOTVGDJFOU
FWJEFODF
UP
DBMDVMBUF
SFMBUJWF
SJTLT
FYJTUJOH
SFTFBSDI
OFWFSUIF
MFTT
SFWFBMT
NVMUJQMF
DPOTUJUVUJPOBM
BOE
QPUFOUJBMMZ
NPEJBCMF
GBDUPST
BTTPDJBUFE
XJUI
BO
JODSFBTFE
SJTL
PG

H ; 9 E C C ; D : 7J ? E D I
TUPNBM
BOE
QFSJTUPNBM
DPNQMJDBUJPOT

Emergency surgery for an ostomy

&WJEFODF
DPODFSOJOH
UIF
JOVFODF
PG
FNFSHFODZ
WFSTVT
QMBOOFE
PTUPNZ
TVSHFSZ
JT
NJYFE
%VDIFTOF
FU
BM

(2002)
DPNQMFUFE
B
DSPTTTFDUJPOBM
TVSWFZ
PG

QFSTPOT
XJUI
DPMPTUPNJFT
BOE
JMFPTUPNJFT
BOE
.BIKPVCJ

FU
BM
(2005)
SFUSPTQFDUJWFMZ
SFWJFXFE
NFEJDBM
SFDPSET
PG

QBUJFOUT
XJUI
FOE
DPMPTUPNJFT
#PUI
HSPVQT

SFQPSUFE
UIBU
FNFSHFODZ
TVSHFSZ
XBT
OPU
BTTPDJBUFE
XJUI
BO
JODSFBTFE
SJTL
GPS
TUPNBM
PS
QFSJTUPNBM
DPN
QMJDBUJPOT
XIFO
DPNQBSFE
UP
DMJFOUT
XIP
VOEFSXFOU
QMBOOFE
PTUPNZ
TVSHFSZ
1BSL
FU
BM
(1999)
SFUSPTQFD
UJWFMZ
BOBMZ[FE
JOUFTUJOBM
TUPNBT
JO
 
DMJFOUT
JODMVEJOH
 
XIPTF
PTUPNZ
XBT
DSFBUFE
EVSJOH
FNFS
HFODZ
TVSHFSZ
4JNJMBS
UP
%VDIFTOF
BOE
.BIKPVCJ
UIFZ
GPVOE
OP
TJHOJDBOU
EJGGFSFODFT
JO
UIF
JODJEFODF

PG
TUPNBM
PS
QFSJTUPNBM
DPNQMJDBUJPOT

*O
DPOUSBTU
UP
UIFTF
OEJOHT
UXP
TUVEJFT
XFSF
JEFOUJFE
UIBU
GPVOE
TUBUJTUJDBMMZ
TJHOJDBOU
BTTPDJBUJPOT

CFUXFFO
TUPNB
TJUJOH
BOE
FNFSHFODZ
WFSTVT
FMFDUJWF
TVSHFSZ
$PUUBN
FU
BM
(2007)
SFQPSUFE
SFTVMUT
PG
B

QSPTQFDUJWF
EFTDSJQUJWF
TUVEZ
PG
 
DMJFOUT
XJUI
JOUFTUJOBM
PTUPNJFT
5IFZ
GPVOE
UIBU
DMJFOUT
XIP
VO
EFSXFOU
FNFSHFODZ
TUPNB
TVSHFSZ
XFSF
TJHOJDBOUMZ
NPSF
MJLFMZ
UP
FYQFSJFODF
QSPCMFNT
SFMBUFE
UP
TUPNB

TJUJOH
UIBO
XFSF
DMJFOUT
NBOBHFE
CZ
FMFDUJWF
TVSHFSZ
"SVNVHBN
FU
BM
(2003)
QSPTQFDUJWFMZ
FWBMVBUFE


DMJFOUT
VOEFSHPJOH
DPMPTUPNZ
PS
JMFPTUPNZ
TVSHFSZ
5IFZ
BMTP
BTTPDJBUFE
FNFSHFODZ
TVSHFSZ
XJUI
B
HSFBUFS

MJLFMJIPPE
PG
TUPNB
TJUJOH
QSPCMFNT
EFOFE
CZ
UIFTF
SFTFBSDIFST
BT
B
TUPNB
TJUFE
JO
BO
BCEPNJOBM
DSFBTF


BOE
B
TJHOJDBOUMZ
IJHIFS
JODJEFODF
PG
QFSJTUPNBM
TLJO
QSPCMFNT

&WJEFODF
GSPN
UIFTF
TUVEJFT
TVHHFTUT
UIBU
XIJMF
FNFSHFODZ
TVSHFSZ
JT
OPU
BTTPDJBUFE
XJUI
BO
PWFSBMM
JO
DSFBTF
JO
UIF
JODJEFODF
PG
TUPNBM
PS
QFSJTUPNBM
DPNQMJDBUJPOT
JU
JT
BTTPDJBUFE
XJUI
BO
JODSFBTFE
MJLFMJIPPE

PG
QPPS
TUPNB
TJUJOH
BOE
SFMBUFE
QPVDIJOH
QSPCMFNT

Stoma height

"
TUVEZ
CZ
$PUUBN
FU
BM
(2007)
PG
 
DMJFOUT
XJUI
JOUFTUJOBM
PTUPNJFT
JEFOUJFE
BO
BTTPDJBUJPO
CFUXFFO

TUPNB
IFJHIU
BOE
UIF
MJLFMJIPPE
PG
TUPNBM
PS
QFSJTUPNBM
DPNQMJDBUJPOT
8IFO
JMFPTUPNJFT
BOE
DPMPTUP
NJFT
BSF
DPNCJOFE
UIF
NFBO
IFJHIU
PG
PTUPNJFT
GPVOE
UP
CF
GSFF
GSPN
DPNQMJDBUJPOT
XBT

NN
BT

DPNQBSFE
UP
B
NFBO
IFJHIU
PG

NN
GPS
PTUPNJFT
XJUI
DPNQMJDBUJPOT
"
MPHJTUJD
SFHSFTTJPO
NPEFM
PG

TUPNB
IFJHIU
BT
B
QSFEJDUPS
PG
PTUPNZ
QSPCMFNT
GPVOE
UIBU
IFJHIUT
MFTT
UIBO

NN
BSF
BTTPDJBUFE
XJUI
B


MJLFMJIPPE
PG
NBOBHFNFOU
QSPCMFNT

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  33
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Gender

&YJTUJOH
FWJEFODF
EFNPOTUSBUFT
UIBU
HFOEFS
JT
OPU
BO
JOEFQFOEFOU
SJTL
GBDUPS
GPS
DPNQMJDBUJPOT
/FJUIFS

%VDIFTOF
FU
BM
(2002)
1BSL
FU
BM
(1999)
OPS
1JUUNBO
FU
BM
(2008)
GPVOE
UIBU
HFOEFS
JOVFODFE
UIF
SJTL
PG

TUPNBM
PS
QFSJTUPNBM
DPNQMJDBUJPOT
$PUUBN
FU
BM
(2007)
SFQPSUFE
UIBU
XPNFO
XFSF
NPSF
MJLFMZ
UIBO
NFO
UP

FYQFSJFODF
DPNQMJDBUJPOT

WT


CVU
MPHJTUJD
SFHSFTTJPO
BOBMZTJT
SFWFBMFE
UIBU
HFOEFS
JOUFSBDUT
XJUI

TUPNB
IFJHIU
BOE
NVMUJQMF
PUIFS
GBDUPST
JODMVEJOH
#.*
BOE
PTUPNZ
UZQF
UP
JOVFODF
DPNQMJDBUJPO
SJTL

Age

.JYFE
FWJEFODF
BMTP
FYJTUT
DPODFSOJOH
UIF
JOVFODF
PG
BHF
PO
UIF
JODJEFODF
PG
TUPNBM
PS
QFSJTUPNBM
DPN
H ; 9 E C C ; D : 7J ? E D I

QMJDBUJPOT
"HF
XBT
BTTPDJBUFE
XJUI
BO
JODSFBTFE
MJLFMJIPPE
PG
FBSMZ
TUPNBM
PS
QFSJTUPNBM
DPNQMJDBUJPOT
JO

UXP
TUVEJFT
FBSMZ
DPNQMJDBUJPOT
XFSF
EFOFE
BT
PDDVSSJOH
XJUIJO
UIF
STU
NPOUI
GPMMPXJOH
PTUPNZ
TVS
HFSZ

(Mahjoubi et al., 2005; Park et al., 1999)
)PXFWFS
1BSL
FU
BM
SFQPSUFE
UIBU
UIJT
EJGGFSFODF
EJTBQQFBSFE

XIFO
POMZ
MBUF
DPNQMJDBUJPOT
XFSF
BOBMZ[FE
5IF
NFBO
BHF
PG
TVCKFDUT
JO
UIF
.BIKPVCJ
FU
BM
TUVEZ
XBT


ZFBST
4%

ZFBST

4VCKFDUT
JO
UIF
1BSL
FU
BM
TUVEZ
XFSF
EFTDSJCFE
BT
WBSZJOH
GSPN
OFPOBUFT
UP

PMEFS
BEVMUT
CVU
EFTDSJQUJWF
TUBUJTUJDT
JEFOUJGZJOH
UIF
NFBO
BHF
PS
BHF
SBOHF
GPS
TVCKFDUT
XBT
OPU
QSPWJEFE

5IF
NFBO
BHF
PG
TVCKFDUT
JO
UIF
$PUUBN
FU
BM
(2007)
TUVEZ
XBT

ZFBST
SBOHF

ZFBST

*O
DPOUSBTU

UP
UIF
OEJOHT
PG
UIF
.BIKPVCJ
BOE
1BSL
HSPVQT
UIFZ
SFQPSUFE
UIBU
BEWBODJOH
BHF
XBT
BTTPDJBUFE
XJUI
B

EJNJOJTIFE
JODJEFODF
PG
DPNQMJDBUJPOT
1JUUNBO
FU
BM
(2008)
FWBMVBUFE
UIF
JODJEFODF
PG
UISFF
PVUDPNFT

SFMBUFE
UP
PTUPNZ
TVSHFSZ
JO
B
HSPVQ
PG

QFSTPOT
XJUI
PTUPNJFT
JODMVEJOH
QFSJTUPNBM
TLJO
QSPCMFNT

4VCKFDUT
JO
UIJT
TUVEZ
IBE
B
SFQPSUFE
NFBO
BHF
PG

ZFBST
SBOHF

ZFBST

4JNJMBS
UP
UIF
OEJOHT

PG
$PUUBNT
HSPVQ
UIFZ
GPVOE
UIBU
BEWBODJOH
BHF
XBT
BTTPDJBUFE
XJUI
B
SFEVDFE
JODJEFODF
PG
QFSJTUPNBM

TLJO
QSPCMFNT
"SVNVHBN
FU
BM
(2003)
FWBMVBUFE

BEVMUT
XJUI
B
NFBO
BHF
PG

ZFBST
4%

ZFBST

SBOHF

ZFBST

BOE
SFQPSUFE
UIBU
BHF
XBT
OPU
SFMBUFE
UP
UIF
JODJEFODF
PG
TUPNBM
PS
QFSJTUPNBM
TLJO

QSPCMFNT

#BTFE
PO
UIFTF
TUVEJFT
JU
JT
OPU
QPTTJCMF
UP
SFMJBCMZ
EFUFSNJOF
UIF
JOVFODF
PG
BHF
BT
BO
JOEFQFOEFOU

SJTL
GBDUPS
GPS
TUPNBM
PS
QFSJTUPNBM
DPNQMJDBUJPOT
"
OVNCFS
PG
GBDUPST
NBZ
BDDPVOU
GPS
UIF
DPOTJEFSBCMF

WBSJBCJMJUZ
JO
TUVEZ
OEJOHT
JODMVEJOH
EJGGFSFODFT
JO
UIF
VOEFSMZJOH
SFBTPOT
GPS
PTUPNZ
TVSHFSZ
JO
EJG
GFSFOU
BHF
HSPVQT
EJGGFSFODFT
JO
UIF
UZQFT
PG
PTUPNJFT
DSFBUFE
JO
UIF
WBSJPVT
BHF
HSPVQT
EJGGFSFODFT
JO

UIF
OVNCFS
BOE
OBUVSF
PG
DPNPSCJE
DPOEJUJPOT
PS
UIF
MJLFMJIPPE
PG
TFFLJOH
IFMQ
XIFO
B
DPNQMJDBUJPO
JT

FYQFSJFODFE

3FTFBSDIFST
IBWF
BMTP
TQFDVMBUFE
BCPVU
UIF
JOVFODF
PG
GBDUPST
JOEJSFDUMZ
BTTPDJBUFE
XJUI
BHJOH
TVDI
BT

EJNJOJTIFE
TFOTPSZ
QFSDFQUJPOT
BMUFSFE
DPHOJUJWF
GVODUJPO
PS
EFDSFBTFE
OF
NPUPS
TLJMMT
(Mahjoubi et al.,
2005; Park et al., 1999; Tseng et al., 2004)
MFBEJOH
UP
SFDPNNFOEBUJPOT
UIBU
JU
JT
JNQPSUBOU
UP
BTTFTT
UIF
JNQBDU

PG
FBDI
PG
UIFTF
GBDUPST
PO
FMEFSMZ
DMJFOUT
BCJMJUZ
UP
NBOBHF
UIFJS
PTUPNZ
BOE
NPOJUPS
GPS
DPNQMJDBUJPOT

34 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Neonatal skin

5IF
TLJO
PG
UIF
QSFNBUVSF
OFPOBUF
IBT
CFFO
JEFOUJFE
BT
B
SJTL
GBDUPS
UIBU
NBZ
JOVFODF
TUPNBM
BOE
QFS
JTUPNBM
DPNQMJDBUJPOT
1SFNBUVSF
OFPOBUFT
QSFTFOU
B
EJNJOJTIFE
DPIFTJPO
CFUXFFO
UIF
EFSNJT
BOE
UIF

FQJEFSNJT
BOE
DBO
CF
BU
SJTL
GPS
TZTUFNJD
UPYJDJUZ
"TTPDJBUJPO
PG
8PNFOT
)FBMUI
0CTUFUSJD
BOE
/FPOBUBM

/VSTFT



Obesity

0CFTJUZ
EFOFE
BT
B
#PEZ
.BTT
*OEFY
LHN

IBT
CFFO
BTTPDJBUFE
XJUI
TUPNBM
SFUSBDUJPO
QSPMBQTF

BOE
OFDSPTJT

BOE
QFSJTUPNBM
TLJO
QSPCMFNT
JO
NVMUJQMF
TUVEJFT
(Argumugam et al., 2003; Cottam et al., 2007;

H ; 9 E C C ; D : 7J ? E D I
Duchesne et al., 2002; Mahjoubi et al., 2005; Richbourg et al., 2007)
)PXFWFS
JU
XBT
OPU
GPVOE
UP
CF
BTTPDJBUFE

XJUI
TUPNBM
PS
QFSJTUPNBM
DPNQMJDBUJPOT
JO
POF
TUVEZ
(Park et al., 1999)

Underlying and co-morbid diseases

6OEFSMZJOH
BOE
DPNPSCJE
DPOEJUJPOT
XFSF
BTTPDJBUFE
XJUI
BO
JODSFBTFE
MJLFMJIPPE
PG
TUPNBM
BOE
QFS
JTUPNBM
DPNQMJDBUJPOT
JO
NVMUJQMF
TUVEJFT
(Arumugam et al., 2003; Cottam et al., 2007; Pittman et al., 2008)

(BTUSPJOUFTUJOBM
EJTPSEFST
BTTPDJBUFE
XJUI
BO
JODSFBTFE
MJLFMJIPPE
PG
DPNQMJDBUJPOT
JODMVEFE
JOBNNB
UPSZ
CPXFM
EJTFBTF
BOE
EJWFSUJDVMJUJT
(Arumugam et al., 2003; Cottam et al., 2007; Duchesne et al., 2002; Pittman
et al., 2008)
%JBCFUFT
NFMMJUVT
BOE
JOBNNBUPSZ
CPXFM
EJTFBTF
XFSF
BTTPDJBUFE
XJUI
B
IJHIFS
JODJEFODF
PG

QFSJTUPNBM
TLJO
QSPCMFNT
(Arumugam et al., 2003; Pittman et al., 2008)

Colostomy, ileostomy versus urostomy

&YJTUJOH
FWJEFODF
DPOTJTUFOUMZ
TVQQPSUT
BO
BTTPDJBUJPO
CFUXFFO
PTUPNZ
UZQF
BOE
UIF
JODJEFODF

BOE
UZQF
PG
TUPNBM
PS
QFSJTUPNBM
DPNQMJDBUJPO
"MUIPVHI
GVSUIFS
SFTFBSDI
PO
UIF
JOVFODF
PG

PTUPNZ
UZQF
JT
OFFEFE
CFGPSF
EFOJUJWF
DPODMVTJPOT
DBO
CF
ESBXO
FYJTUJOH
FWJEFODF
TVQQPSUT
UIF
GPMMPX
JOH
DPODMVTJPOT

1)

*MFPTUPNJFT
BSF
BTTPDJBUFE
XJUI
B
IJHIFS
JODJEFODF
PG
QFSJTUPNBM
TLJO
QSPCMFNT
UIBO
BSF
DPMPTUP
NJFT
(Duchesene et al., 2002; Herlufsen et al., 2006; Pittman et al., 2008)
$PUUBN
FU
BM
(2007)
BOE
1BSL

FU
BM (1999)
SFQPSUFE
UIBU
DSFBUJPO
PG
B
MPPQ
JMFPTUPNZ
XBT
BTTPDJBUFE
XJUI
TJHOJDBOUMZ
NPSF

DPNQMJDBUJPOT
UIBO
FOE
JMFPTUPNJFT
PS
DPMPTUPNJFT

2)

6SPTUPNJFT
BSF
BTTPDJBUFE
XJUI
B
IJHIFS
JODJEFODF
PG
QFSJTUPNBM
TLJO
QSPCMFNT
UIBO
DPMPTUPNJFT

(Herlufsen et al., 2006)

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  35
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

RECOMMENDATION 11
H[l_[mj^[Yb_[djic[Z_YWj_edfheb[je[dikh[j^WjcWn_ckcWXiehfj_edWdZ[\\[Yj_l[d[ii
m_bbX[WY^_[l[Z_dh[bWj_edjej^[jof[e\eijeco$
B[l[be\;l_Z[dY[3?L

Discussion of Evidence

$MJFOUT
XJUI
BO
JMFPTUPNZ
PS
DPMPTUPNZ
NBZ
FYQFSJFODF
DIBOHFT
JO
NFEJDBUJPO
BCTPSQUJPO
CFDBVTF
PG
UIF

TIPSUFOFE
MFOHUI
PG
CPXFM
BT
B
SFTVMU
PG
PTUPNZ
TVSHFSZ
5IJT
QFSUBJOT
QBSUJDVMBSMZ
UP
UIF
DMJFOU
XJUI
BO

H ; 9 E C C ; D : 7J ? E D I

JMFPTUPNZ
BT
NPTU
NFEJDBUJPOT
BSF
BCTPSCFE
JO
UIF
JMFVN
0CTFSWJOH
SFTJEVBM
QJFDFT
PG
NFEJDBUJPO
JO
UIF

DMJFOUT
PTUPNZ
QPVDI
NBZ
TVHHFTU
UIBU
DPOTJEFSBUJPO
TIPVME
CF
HJWFO
UP
QSFTDSJCF
BMUFSOBUJWF
GBTUBDUJOH

GPSNVMBT
TVDI
BT
VODPBUFE
UBCMFUT
HFMBUJO
DBQTVMFT
TPMVUJPOT
PS
TVTQFOTJPOT
UP
NBYJNJ[F
UIFSBQFVUJD

BCTPSQUJPO
.FEJDBUJPOT
DBO
BMTP
DBVTF
B
DIBOHF
JO
PEPVS
DPMPVS
BOE
DPOTJTUFODZ
PG
GFDFT
8IFUIFS
UIF

NFEJDBUJPO
JT
QSFTDSJCFE
PS
PWFSUIFDPVOUFS
UIF
DMJFOU
NVTU
CF
FEVDBUFE
BCPVU
UIF
NFEJDBUJPOT
UBLFO

BOE
UIF
FGGFDU
JU
XJMM
IBWF
PO
UIF
GVODUJPO
PG
UIF
PTUPNZ
$MJFOUT
XIP
IBWF
B
VSJOBSZ
PTUPNZ
EP
OPU
FYQFSJ
FODF
UIF
TBNF
DPODFSO
PG
NBMBCTPSQUJPO
CFDBVTF
UIF
TNBMM
CPXFM
VTFE
UP
DPOTUSVDU
UIF
JMFBM
DPOEVJU
JT
PG

OP
DPOTFRVFODF
)PXFWFS
B
EJTDPMPVSBUJPO
PG
UIF
VSJOF
JT
UIF
NPTU
DPNNPO
PG
NFEJDBUJPO
TJEF
FGGFDUT

&TUBCMJTIJOH
B
UIFSBQFVUJD
SFMBUJPOTIJQ
XJUI
B
QIBSNBDJTU
QSPWJEFT
UIF
DMJFOU
XJUI
B
TPVSDF
GPS
POHPJOH

DPOTVMUBUJPO
BOE
FEVDBUJPO
XIJDI
QSPNPUFT
JOEFQFOEFODF
4FF
"QQFOEJY
)
GPS
B
MJTU
PG
NFEJDBUJPOT
BOE

PTUPNZ
GVODUJPO
'PS
NFEJDJOBM
JNQMJDBUJPOT
BGGFDUJOH
UIF
OFPOBUFQFEJBUSJD
DMJFOU
QMFBTF
DPOTVMU
B
QIBS
NBDJTU
BOEPS
UIF
$PNQFOEJVN
PG
1IBSNBDFVUJDBMT
BOE
4QFDJBMUJFT
$14


RECOMMENDATION 12
7le_Z_di[hj_ede\W]boY[h_dikffei_jeho_djeWYebeijeco_dehZ[hjeW_Z[lWYkWj_ede\[\k[dj$
B[l[be\;l_Z[dY[3?X

Discussion of Evidence

.D$MFFT
FU
BM
(2004)
DPNQBSFE
GFDBM
PVUQVU
GFDBM
WPMVNF
BOE
BUVT
VTJOH
B
HMZDFSJO
TVQQPTJUPSZ
JO
B
SBO
EPNJ[FE
DSPTTPWFS
TUVEZ
PG
FJHIU
BEVMUT
XJUI
DPMPTUPNJFT
4VCKFDUT
XFSF
SBOEPNMZ
BTTJHOFE
UP
FNQUZJOH

XJUI
UIF
BJE
PG
B
HMZDFSJO
TVQQPTJUPSZ
JOTFSUFE
JOUP
UIF
PTUPNZ
EBJMZ
BT
DPNQBSFE
UP
UIFJS
VTVBM
NFUIPE

PG
FNQUZJOH
QPVDI
POMZ
GPS
UISFF
QPVDI
QMVT
JSSJHBUJPO
GPS
WF

"GUFS
UXP
XFFLT
TVCKFDUT
XFSF
DSPTTFE

PWFS
UP
UIF
BMUFSOBUJWF
HSPVQ
GPS
BO
BEEJUJPOBM
UXP
XFFLT
PG
EBUB
DPMMFDUJPO
%BJMZ
JOTFSUJPO
PG
B
TVQQPTJUPSZ

EJE
OPU
JOVFODF
GFDBM
PVUQVU
GFDBM
WPMVNF
PS
BUVT
XIFO
DPNQBSFE
UP
VTVBM
NFUIPET
PG
FNQUZJOH
UIFJS

DPMPTUPNZ
5IF
MBDL
PG
FGDBDZ
PG
UIF
TVQQPTJUPSZ
XBT
QBSUMZ
BUUSJCVUFE
UP
JUT
GBJMVSF
UP
SFNBJO
JO
UIF
CPXFM

GPS
BO
BEFRVBUF
QFSJPE
PG
UJNF
"MUIPVHI
UIF
TBNQMF
TJ[F
XBT
TNBMM
UIJT
DSPTTPWFS
SBOEPNJ[FE
DMJOJDBM

USJBM
QSPWJEFT
MJNJUFE
FWJEFODF
UIBU
B
HMZDFSJO
TVQQPTJUPSZ
EPFT
OPU
QPTJUJWFMZ
JOVFODF
GFDBM
PVUQVU
WPM
VNF
PS
BUVT
"
DPOTFOTVT
PG
UIF
FYQFSU
QBOFM
DPODMVEFE
UIBU
UIF
BENJOJTUSBUJPO
PG
TVQQPTJUPSJFT
JO
UIF

QFEJBUSJD
BOE
BEVMU
QPQVMBUJPO
JT
JOFGGFDUJWF
BOE
OPU
SFDPNNFOEFE
JO
BOZ
UZQF
PG
TUPNB

36 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

RECOMMENDATION 13
9ekdi[bb_d]XoWH[]_ij[h[Z:_[j_j_Wdi^ekbZX[f[h\ehc[Z\ehYb_[djim_j^Wdeijecom^eWh[Wjh_ia
\eh"ehm^eZ[l[bef"dkjh_j_edWbYecfb_YWj_edi$
B[l[be\;l_Z[dY[3??W

Discussion of Evidence

Weight

H ; 9 E C C ; D : 7J ? E D I
8FJHIU
HBJO
PS
MPTT
QPTUPTUPNZ
DSFBUJPO
DBO
BMUFS
UIF
TIBQF
PG
UIF
BCEPNFO

-FBLBHF
PG
GFDFT
PS
VSJOF

DBO
PDDVS
JG
UIF
BQQMJBODF
JT
OP
MPOHFS
TFDVSF
(Burch, 2007)

Special dietary needs

$MJFOUT
XIP
DIFX
QPPSMZ
TFDPOEBSZ
UP
JMM
UUJOH
EFOUVSFT
NJTTJOH
UFFUI
PS
XIP
BSF
SBQJE
FBUFST
BSF
BU

HSFBUFS
SJTL
GPS
NBMEJHFTUJPO
BOE
QPUFOUJBM
GPS
CMPDLBHF
(Burch, 2006)
0OF
PG
UIF
NBJO
PQQPSUVOJUJFT
GPS

UIF
CPEZ
UP
CSFBL
EPXO
GPPE
CFHJOT
XJUI
BEFRVBUF
DIFXJOH
NBTUJDBUJPO

1PPSMZ
DIFXFE
GPPE
PGUFO
XJMM

BQQFBS
VOEJHFTUFE
JO
UIF
PTUPNZ
QPVDI
BOE
DBVTF
DPODFSO
GPS
UIF
DMJFOU
UIBU
UIFZ
BSF
OPU
BCTPSCJOH
UIFJS

GPPE
(Price, 1989)
*G
UIF
DMJFOU
JT
VOBCMF
UP
BEFRVBUFMZ
DIFX
UIFJS
GPPE
UIFO
B
EJFU
BMUFSFE
JO
UFYUVSF
PS
UIF

FMJNJOBUJPO
PG
B
GFX
DPODFSOJOH
GSVJUT
BOE
WFHFUBCMFT
TVDI
BT
DPSO
QPQDPSO
OVUT
DFMFSZ

NBZ
CF
BQQSP
QSJBUF
*U
JT
JNQPSUBOU
UIBU
UIJT
JT
JOEJWJEVBMJ[FE
GPS
FBDI
DMJFOU

4PNF
DMJFOUT
NBZ
IBWF
CFFO
GPMMPXJOH
B
SFTUSJDUJWF
PS
TQFDJBM
EJFU
QSJPS
UP
UIF
DSFBUJPO
PG
BO
PTUPNZ
5IF

PTUPNZ
IPXFWFS
NBZ
BMMFWJBUF
UIF
OFFE
GPS
SFTUSJDUJPOT
BOE
JO
NBOZ
DBTFT
B
DMJFOU
DBO
SFUVSO
UP
B
OPSNBM

EJFU
5IJT
JT
FTQFDJBMMZ
USVF
GPS
UIF
DMJFOU
XJUI
VMDFSBUJWF
DPMJUJT
XIPTF
EJTFBTF
IBT
CFFO
QFSNBOFOUMZ
SF
NPWFE
XJUI
B
UPUBM
DPMFDUPNZ
PS
B
TVSHJDBM
SFNPWBM
PG
BO
PCTUSVDUJOH
DBODFS
*G
UIFSF
JT
QFSNBOFOU
EBNBHF

UP
UIF
SFNBJOJOH
CPXFM
GSPN
SBEJBUJPO
PS
BDUJWF
$SPIOT
EJTFBTF
UIF
QSFWJPVTMZ
QSFTDSJCFE
EJFU
NBZ
OFFE

UP
CF
DPOUJOVFE
PS
NPEJFE
JO
SFMBUJPO
UP
UIF
PTUPNZ

High output and dehydration

*MFPTUPNZ
PVUQVU
JT
VTVBMMZ
NM
QFS
EBZ
(Doughty, 2005; Gallagher & Gates, 2004)
)JHI
PVUQVU

CFZPOE
UIFTF
MFWFMT
DBO
CF
SFMBUFE
UP
QSFFYJTUJOH
EJTFBTF
QBSUJBM
CMPDLBHF
DFSUBJO
GPPET
TUJNVMBUJOH
UIF

NPUJPO
PG
UIF
CPXFM
NFEJDBUJPOT
PS
TIPSUFOFE
CPXFM
XJUI
JOBEFRVBUF
BCTPSQUJWF
TVSGBDF
*OBCJMJUZ
UP

NBJOUBJO
PSBM
JOUBLF
XJUI
IJHI
PVUQVU
DBO
MFBE
UP
EFIZESBUJPO
TFF
"QQFOEJY
*
GPS
TJHOT
BOE
TZNQUPNT

PG
EFIZESBUJPO

4PNF
GPPET
NBZ
IFMQ
UIJDLFO
PS
MPPTFO
UIF
TUPPM
XIJDI
NBZ
CF
CFOFDJBM
PS
BWPJEFE
GPS

TQFDJD
DPODFSOT
TVDI
BT
IJHI
FGVFOU
JO
BO
JMFPTUPNZ
PS
DPOTUJQBUJPO
JO
B
DPMPTUPNZ
TFF
"QQFOEJY
*
GPS

GPPET
UIBU
MPPTFOUIJDLFO
TUPPM

5IF
QSFTFODF
PG
BO
JOUBDU
DPMPO
XPVME
BCTPSC
DD
BEEJUJPOBM
VJE

BOE
UIFSFGPSF
BO
JODSFBTF
PG

DVQT
PG
VJET
PSBMMZ
JT
SFRVJSFE
UP
NFFU
IZESBUJPO
OFFET
(Doughty, 2005)

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  37
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

&MFDUSPMZUF
MPTTFT
DBO
CF
FWJEFOU
XJUI
B
IJHI
PVUQVU
JMFPTUPNZ
BT
UIF
DPMPO
JT
UIF
QSJNBSZ
BCTPSQUJWF
BSFB

GPS
TPEJVN
BOE
QPUBTTJVN
%BJMZ
DPOTVNQUJPO
PG
GPPET
SJDI
JO
TPEJVN
BOE
QPUBTTJVN
JT
VTVBMMZ
TVG
DJFOU
UP
DPSSFDU
PS
QSFWFOU
UIJT
EFQMFUJPO
4PNF
DMJOJDJBOT
TVHHFTU
TQPSU
ESJOLT
XJUI
FMFDUSPMZUF
BEEJUJWFT

IPXFWFS
UIFTF
BSF
FYQFOTJWF
BOE
IBWF
OP
SFBM
CFOFU
XIFO
DPNQBSFE
UP
GPPET
SJDI
JO
QPUBTTJVN
BOE

TPEJVN
TFF
"QQFOEJY
*
GPS
B
MJTU
PG
IJHI
TPEJVN
BOE
QPUBTTJVN
GPPE
TPVSDFT
BOE
TQPSU
ESJOLT

1VSQPTF
GVM
PWFSIZESBUJPO
DPOTVNJOH
FYDFTTJWF
VJE
JF
MJUSFT
QFS
EBZ

DBO
BSUJDJBMMZ
MPXFS
FMFDUSPMZUFT
BOE

DBVTF
XBUFS
UPYJDJUZ
(SFBUFS
XBUFS
JOUBLF
CFZPOE
OFDFTTBSZ
IPXFWFS
EPFT
OPU
BQQFBS
UP
JODSFBTF
UIF
JMFBM

FGVFOU
(Kramer, 1987)

Bowel obstruction/blockage
H ; 9 E C C ; D : 7J ? E D I

#MPDLBHF
PG
BO
PTUPNZ
DBO
CF
WFSZ
QBJOGVM
BOE
JOJUJBMMZ
NPTU
DMJFOUT
BSF
GFBSGVM
PG
UIJT
PDDVSSFODF
5P
NJOJ
NJ[F
UIF
QPUFOUJBM
GPS
CMPDLBHF
EVSJOH
UIF
TUPNBT
QPTUPQFSBUJWF
FEFNBUPVT
QIBTF
PG
BCPVU

XFFLT

(Floruta, 2001; Gallagher & Gates, 2004)
JU
JT
BEWJTBCMF
UP
SFEVDF
UIF
CSPVT
NBUFSJBM
JO
UIF
EJHFTUJWF
USBDU
JF

UIBU
XIJDI
JT
SFTJTUBOU
UP
CSFBLEPXO

GPS
B
TIPSU
UJNF
FTQFDJBMMZ
XJUI
BO
JMFPTUPNZ
(Floruta, 2001)
"
GPPE

CMPDLBHF
DBO
PDDVS
XIFO
JOTPMVCMF
CSF
CFDPNFT
MPEHFE
QSPYJNBM
UP
UIF
TUPNB
(Doughty, 2005)
"
RVFT
UJPOOBJSF
UP

PTUPNZ
DMJFOUT
'MPSVUB


SFWFBMFE
UIBU
BMUIPVHI

TUBUFE
UIFZ
XFSF
OPU
GPMMPXJOH

B
TQFDJBM
EJFU

JOEJDBUFE
UIBU
UIFZ
BWPJEFE
DFSUBJO
GPPET
EVF
UP
UIF
QPUFOUJBM
GPS
PTUPNZ
CMPDLBHF
"Q
QFOEJY
*
MJTUT
GPPET
UIBU
BSF
DPNNPOMZ
BWPJEFE
EVSJOH
UIJT
QPTUPQFSBUJWF
UJNF
BOE
HFOFSBM
JOTUSVDUJPO
PO

EJFU
SFMBUFE
UP
PCTUSVDUJPO

Constipation

$POTUJQBUJPO
JT
QSJNBSJMZ
BO
JTTVF
SFMBUFE
UP
B
EJTUBM
DPMPTUPNZ
"EFRVBUF
VJE
JOUBLF
GPS
BEVMUT
PS
DIJMESFO

TIPVME
BMMFWJBUF
IBSE
TUPPMT
BMPOH
XJUI
UIF
JODMVTJPO
PG
IJHIMZ
CSPVT
GPPE
DIPJDFT

RECOMMENDATION 14
Fh[fWh[j^[Yb_[djWdZ\Wc_boXoj[WY^_d]Wjb[Wijj^[c_d_ckcia_bbi[jif[Y_Yjej^[_hd[[Zi
fh_ehjeZ_iY^Wh][\hec^eif_jWb$
B[l[be\;l_Z[dY[3?L

Discussion of Evidence

5SBEJUJPOBMMZ
DMJFOUT
XFSF
UBVHIU
IPX
BOE
XIFO
UP
FNQUZ
UIF
PTUPNZ
QPVDI
UIF
QSPDFEVSF
GPS
SFNPWJOH

BOE
BQQMZJOH
B
OFX
QPVDI
QFSJTUPNBM
TLJO
DBSF
UIF
FGGFDUT
PG
EJFU
PO
UIF
PTUPNZ
TFMGNPOJUPSJOH
GPS

TUPNBM
PS
QFSJTUPNBM
DPNQMJDBUJPOT
BOE
FGGFDUT
PO
BQQFBSBODF
PG
DMPUIJOH
EVSJOH
UIF
JNNFEJBUF
QPTU
PQFSBUJWF
QFSJPE
BOE
CFGPSF
IPTQJUBM
EJTDIBSHF
)PXFWFS
BEWBODFT
JO
TVSHJDBM
UFDIOJRVF
IBWF
ESBNBUJ
DBMMZ
SFEVDFE
NFBO
IPTQJUBM
TUBZT
'PS
FYBNQMF
UIF
NFBO
IPTQJUBM
TUBZ
GPMMPXJOH
TJHNPJE
DPMPO
SFTFDUJPO

SFTVMUJOH
JO
DSFBUJPO
PG
B
DPMPTUPNZ
JT
WF
EBZT
BOE
UIF
NFBO
TUBZ
GPS
MBQBSPTDPQJD
QSPDUPDPMFDUPNZ
XJUI

DSFBUJPO
PG
BO
JMFPTUPNZ
JT

EBZT (Colwell & Gray, 2007).
"T
B
SFTVMU
OVSTFT
BSF
DIBMMFOHFE
UP
BDDPNNP
EBUF
UIF
FEVDBUJPOBM
OFFET
PG
B
DMJFOU
XJUI
B
OFX
PTUPNZ
JO
UPEBZT
IPTQJUBM
TFUUJOH
8IJMF
OP
SFTFBSDI
FY
JTUT
UP
EFOF
B
NJOJNVN
QPTUPQFSBUJWF
TLJMM
TFU
GPS
DMJFOUT
XJUI
B
OFX
PTUPNZ
B
DPOTFOTVT
DPOGFSFODF
PG

38 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

8PVOE
0TUPNZ
BOE
$POUJOFODF
/VSTFT
JO
UIF
6OJUFE
4UBUFT
(Wound, Ostomy and Continence Nurses Society,

2007) DPODMVEFE
UIBU
UIF
NJOJNVN
QPTUPQFSBUJWF
TLJMM
TFU
GPS
QFSTPOT
XJUI
BO
PTUPNZ
TIPVME
JODMVEF



BCJMJUZ
UP
NBOJQVMBUF
UIF
QPVDI
DMJQ
PS
TQPVU
JG
QSFTFOU
BOE


JOEFQFOEFOUMZ
FNQUZ
UIF
QPVDI
"EEJUJPOBM

TLJMMT
UIBU
OFFE
UP
CF
UBVHIU
XIFOFWFS
QPTTJCMF
JODMVEFE


CBUIJOH
DMPUIJOH
BOE
BDUJWJUZ
SFTUSJDUJPOT



SFWJFX
PG
JOVFODF
PG
QSFTDSJQUJPO
BOE
PWFSUIFDPVOUFS
NFEJDBUJPOT
PO
PTUPNZ
GVODUJPO


JOVFODF
PG

EJFU
PO
PTUPNZ
GVODUJPO


QFSJTUPNBM
TLJO
DBSF


PEPVS
DPOUSPM


NPOJUPSJOH
GPS
DPNQMJDBUJPOT
BOE



TFYVBM
DPVOTFMJOH
(Colwell & Gray, 2007).

"
DPOTFOTVT
PG
FYQFSU
PQJOJPO
BNPOH
QBOFM
NFNCFST
EFOFE
UIF
GPMMPXJOH
JOGPSNBUJPO
UP
CF
UBVHIU
UP

DMJFOU
BOE
GBNJMZ
EVSJOH
UIF
JNNFEJBUF
QPTUPQFSBUJWF
QFSJPE
GPMMPXJOH
DSFBUJPO
PG
BO
PTUPNZ

H ; 9 E C C ; D : 7J ? E D I
n
SFWJFX
PG
FEVDBUJPOBM
WJEFP$%
BCPVU
TUPNB
DBSF
n
PCTFSWBUJPO
PG
B
MFBTU
POF
DPNQMFUF
BQQMJBODF
TZTUFN
DIBOHF
n
JOEFQFOEFODF
XJUI
FNQUZJOH
UIF
QPVDI

n
XIFSF
UP
PCUBJO
TVQQMJFT
n
OBODJBM
BTTJTUBODF
GPS
TVQQMJFT
FH
0OUBSJP
"TTJTUJWF
%FWJDFT
1SPHSBN



n
CBUIJOH
DMPUIJOH
BOE
BDUJWJUZ
SFTUSJDUJPOT

n
JNNFEJBUF
EJFUBSZ
SFTUSJDUJPOT
JG
BQQSPQSJBUF

n
SFWJFX
PG
NFEJDBUJPOT

QSFTDSJQUJPO
BOE
PWFSUIFDPVOUFS
JG
BQQSPQSJBUF

n
HFOFSBM
PWFSWJFX
PG
PTUPNZ
MJUFSBUVSF
QSPWJEFE
BU
EJTDIBSHF
n
FNFSHFODZ
QIPOF
OVNCFS
GPS
BTTJTUBODF

0UIFS
UPQJDT
EFQFOEJOH
PO
UIF
OFFET
PG
UIF
DMJFOU
BOE
GBNJMZ
DPVME
JODMVEF

n
BEKVTUJOH
BQQMJBODF
UP
TUPNB
TJ[F
n
EJFU
MPOH
UFSN

n
HFOFSBM
TLJO
DBSF

n
PEPVS
DPOUSPM

n

DPNQMJDBUJPOT

DMJFOUT
TIPVME
CF
UBVHIU
IPX
UP
QSFWFOU
BOEPS
SFDPHOJ[F
TJHOT
BOE
TZNQUPNT
PG

a.
QFSJTUPNBM
TLJO
QSPCMFNT



b.
PCTUSVDUJPO



c.
IFSOJBUJPO
n
TFYVBM
DPVOTFMMJOH

n
USBWFM
DPOTJEFSBUJPOT

n

B

DDFTTJOH
DPNNVOJUZ
SFTPVSDFT
JODMVEJOH
UIF
TFMGIFMQ
HSPVQ
UIF
6OJUFE
0TUPNZ
"TTPDJBUJPO
PG

$BOBEB
JO
UIFJS
BSFB

4FF
"QQFOEJY
&
BOE
+
GPS
FYBNQMFT
PG
0TUPNZ
5FBDIJOH
'MPX
4IFFUT

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  39
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

RECOMMENDATION 15
:_iY^Wh][j^[Yb_[djWdZ\Wc_bom_j^^ec[YWh[ikffehj$
B[l[be\;l_Z[dY[3?X

Discussion of Evidence

"EEJT
(2003)
SFQPSUFE
B
SBOEPNJ[FE
DMJOJDBM
USJBM
PG

QBUJFOUT
XJUI
OFXMZ
DSFBUFE
DPMPTUPNJFT
PS
JMFPT
UPNJFT
4VCKFDUT
XFSF
SBOEPNJ[FE
UP
SFDFJWF
IPNF
WJTJUT

EBZT
BGUFS
EJTDIBSHF
BOE
NPOUIMZ
GPS
UIF

OFYU
TJY
NPOUIT
$POUSPM
HSPVQ
TVCKFDUT
SFDFJWFE
IPNF
WJTJUT
BU
NPOUIT
UISFF
BOE
TJY
GPMMPXJOH
IPTQJUBM

H ; 9 E C C ; D : 7J ? E D I

EJTDIBSHF
4VCKFDUT
SFDFJWJOH
TJY
IPNF
WJTJUT
IBE
TJHOJDBOUMZ
IJHIFS
IFBMUISFMBUFE
RVBMJUZ
PG
MJGF
TDPSFT

BGUFS
UISFF
NPOUIT
XIFO
DPNQBSFE
UP
DPOUSPM
TVCKFDUT
1BUJFOUT
SBOEPNJ[FE
UP
TJY
IPNF
WJTJUT
BMTP
EFN
POTUSBUFE
TJHOJDBOUMZ
HSFBUFS
JOEFQFOEFODF
XJUI
DBSF
BU
TJY
NPOUIT
"MUIPVHI
GVSUIFS
SFTFBSDI
JT
OFFEFE

UP
FMVDJEBUF
UIF
SBOHF
PG
CFOFUT
BTTPDJBUFE
XJUI
IPNF
DBSF
TVQQPSU
EBUB
GSPN
UIJT
SBOEPNJ[FE
DMJOJDBM

USJBM
EFNPOTUSBUF
UIBU
WJTJUT
GSPN
IPNF
DBSF
OVSTFT
JNQSPWF
CPUI
TFMGFGDBDZ
BOE
RVBMJUZ
PG
MJGF
JO
DMJFOUT

MJWJOH
XJUI
BO
PTUPNZ

1MBOOJOH
GPS
EJTDIBSHF
GSPN
IPTQJUBM
SFRVJSFT
DPMMBCPSBUJPO
BOE
DPPSEJOBUJPO
PG
TFSWJDFT
BOE
SFTPVSDFT

5IF
OVSTF
QMBZT
B
QJWPUBM
SPMF
JO
EFTJHOJOH
UIJT
QBSU
PG
UIF
DBSF
QMBO
&BSMZ
DPOTJEFSBUJPO
TIPVME
CF
HJWFO

UP
SFGFSSBMT
SFRVJSFE
GPS
DPNNVOJUZ
DBSF
OVSTJOH
TFSWJDFT
BOE
&5/
DPOUBDU
BQQMJDBUJPO
GPS
OBODJBM
BTTJT
UBODF
UP
TVQQPSU
UIF
QVSDIBTF
PG
PTUPNZ
TVQQMJFT
BSSBOHFNFOUT
GPS
BO
PTUPNZ
WJTJUPS
UIF
USBJOJOH
PG
PUIFS

DBSF
QSPWJEFST
JO
UIF
DMJFOUT
PTUPNZ
DBSF
QSPUPDPM
BOE
GPMMPXVQ
BQQPJOUNFOUT
XJUI
UIF
&5/
"MUIPVHI

UIF
DMJFOUT
DBSF
SFRVJSFNFOUT
XJMM
FWPMWF
BOE
DIBOHF
UISPVHIPVU
UIF
QPTUPQFSBUJWF
QFSJPE
UIF
JNQPSUBODF

PG
QMBOOJOH
GPS
EJTDIBSHF
DPOWFZT
DBSF
BOE
DPOEFODF
JO
UIF
DMJFOUT
BCJMJUZ
UP
SFUVSO
IPNF
*U
BMTP
BWPJET

MBTU
NJOVUF
BSSBOHFNFOUT
PS
PWFSTJHIUT
XIJDI
DPVME
IBWF
B
OFHBUJWF
JNQBDU
PO
FOTVSJOH
B
DMJFOUDFOUSFE

EJTDIBSHF
QMBO
4FF
"QQFOEJY
,
GPS
OBNFT
BOE
QIPOF
OVNCFST
PG
UIF
0OUBSJP
DIBQUFS
PG
6OJUFE
0TUPNZ

"TTPDJBUJPO
PG
$BOBEB
4FF
"QQFOEJY
-
GPS
SFTPVSDF
JOGPSNBUJPO
PO
PTUPNZ
BTTPDJBUJPOT
NBOVGBDUVSFST

DMPUIJOH
BOE
BDDFTTPSJFT
BOE
OBODFT

4FF
"QQFOEJY
.
GPS
B
TBNQMF
0TUPNZ
$BSF
'PSN

RECOMMENDATION 16
;dikh[j^Wjj^[eijecofbWde\YWh[_i_dZ_l_ZkWb_p[Zjec[[jj^[d[[Zie\j^[Yb_[djWdZ\Wc_bo$
B[l[be\;l_Z[dY[3?L

Discussion of Evidence

"
DPOTFOTVT
PG
FYQFSU
PQJOJPO
TVQQPSUT
JOEFQFOEFOU
TFMGDBSF
PG
UIF
PTUPNZ
BT
B
EFTJSBCMF
HPBM
GPS
NPTU

BEVMUT
(PBMT
PG
DBSF
JODMVEF
BO
PTUPNZ
UIBU
JT
GSFF
PG
MFBLBHF
PEPVS
BOE
DPNQMJDBUJPOT
8V
$IBV
BOE

5XJOO
(2007)
FWBMVBUFE
TFMGFGDBDZ
JO
PTUPNZ
DBSF
JO
B
HSPVQ
PG

TVCKFDUT
5IFZ
SFQPSUFE
UIBU
TVCKFDUT

XJUI
B
IJHIFS
TFMGFGDBDZ
JO
PTUPNZ
DBSF
IBE
IJHIFS
IFBMUISFMBUFE
RVBMJUZ
PG
MJGF
TDPSFT
'BDUPST
BTTPDJBUFE

XJUI
MPXFS
TFMGFGDBDZ
JO
PTUPNZ
DBSF
JODMVEFE
JODSFBTJOH
BHF
MPXFS
FEVDBUJPOBM
MFWFMT
BOE
SFMJBODF
PO

PUIFST
UP
QFSGPSN
PTUPNZ
DBSF
TVDI
BT
QPVDI
DIBOHFT
4FF
"QQFOEJY
/
GPS
DBSF
TUSBUFHJFT
GPS
UIF
DMJFOU

XJUI
TQFDJBM
OFFET

40 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

8IJMF
OP
TUVEZ
XBT
JEFOUJFE
UIBU
DPNQBSFE
TJNQMJDJUZ
PG
PTUPNZ
QSPEVDU
VTF
UP
QPVDI
XFBS
UJNF
GSF
RVFODZ
PG
MFBLBHF
PS
JODJEFODF
PG
DPNQMJDBUJPOT
FYQFSU
PQJOJPO
BMTP
TVQQPSUT
TFMFDUJPO
PG
UIF
TJNQMFTU

QPTTJCMF
PTUPNZ
QSPEVDU
BQQSPQSJBUF
UP
NFFU
UIF
DMJFOUT
OFFET
#PVSLF
BOE
%BWJT
(2002)
SFQPSUFE
SFTVMUT

PG
B
TVSWFZ
PG
 
QFSTPOT
MJWJOH
XJUI
BO
PTUPNZ
GPMMPXJOH
JOTUJUVUJPO
PG
B
QSPHSBN
QSPWJEJOH
BDDFTT

UP
PTUPNZ
TVQQMJFT
XJUIPVU
EJSFDU
DPTU
UP
UIF
DMJFOU

.PSF
UIBO
IBMG
PG
XPNFO


BOE
NFO



SFQPSUFE
DIBOHJOH
UIF
UZQF
PG
PTUPNZ
BQQMJBODF
VTFE
UP
NBOBHF
UIFJS
TUPNBT
5IF
NPTU
DPNNPOMZ
DJUFE

SFBTPO
GPS
DIBOHJOH
UIF
UZQF
PG
PTUPNZ
BQQMJBODF
XBT
FBTF
PG
VTF

5IFSFGPSF
JU
JT
WJUBM
UIBU
UIF
CFTU
QPTTJCMF
PTUPNZ
TZTUFN
JT
DIPTFO
XJUI
UIFTF
HPBMT
JO
NJOE
BOE
UIF

TQFDJD
OFFET
BOE
QSFGFSFODF
PG
UIF
DMJFOU
"U
UIJT
UJNF
UIFSF
BSF
B
OVNCFS
PG
DPNQBOJFT
JO
$BOBEB
UIBU

NBSLFU
OVNFSPVT
PTUPNZ
QSPEVDUT
BOE
BDDFTTPSJFT
5IF
&5/
PS
PTUPNZ
OVSTF
TQFDJBMJTU
DBO
CFTU
BTTFTT

H ; 9 E C C ; D : 7J ? E D I
BOE
SFDPNNFOE
QSPEVDU
TFMFDUJPO
TVJUFE
UP
UIF
DMJFOUT
PS
GBNJMZT
DBSF
SFRVJSFNFOUT
)PXFWFS
JU
JT
JN
QPSUBOU
UIBU
UIF
DMJFOU
JT
JOWPMWFE
JO
UIF
EFDJTJPONBLJOH
QSPDFTT
GPS
UIF
TFMFDUJPO
4FF
"QQFOEJY
0
GPS
B

MJTU
PG
PTUPNZ
QSPEVDUT

5IF
GPMMPXJOH
BSF
GBDUPST
XIJDI
NVTU
CF
DPOTJEFSFE
XIFO
TFMFDUJOH
BO
PTUPNZ
QSPEVDU

n

UZQF
PG
PTUPNZ
GFDBM
PS
VSJOF

n


UZQF
PG
TUPNB
DPOTUSVDUJPO

n


JOGBOU
DIJME
PS
BEVMU
DMJFOU

n


MPDBUJPO
PG
TUPNB

n


DIBSBDUFSJTUJDT
PG
UIF
TUPNB

n


DIBSBDUFSJTUJDT
PG
UIF
QFSJTUPNBM
TLJO

n


TLJO
TFOTJUJWJUJFT
PS
BMMFSHJFT

n


NBOVBM
EFYUFSJUZ
BOE
QIZTJDBM
JNQBJSNFOUT
GPS
NBOBHFNFOU

n


DPHOJUJWF
BCJMJUJFT
GPS
MFBSOJOH

n


DMJFOUT
QFSTPOBM
QSFGFSFODFT

n


MJWJOH
TJUVBUJPO
IPNF
MPOHUFSN
DBSF
HSPVQ
IPNF

n


PDDVQBUJPOBM
JNQMJDBUJPOT

n


SFMJHJPVT
QSBDUJDFT

n


DPTU

n


MJGFTUZMF

n


BDDFTTJCJMJUZ
PG
QSPEVDUT

n


BNPVOU
BOE
DPOTJTUFODZ
PG
UIF
FGVFOU

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  41
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

RECOMMENDATION 17
7ii[iic[djWdZ\ebbem#kfXoWd;dj[heijecWbJ^[hWfoDkhi[;JDWh[h[Yecc[dZ[Z\ehj^[Yb_[dj
WdZ\Wc_boW\j[heijecoikh][hojeZ[Yh[Wi[fioY^ebe]_YWbZ_ijh[ii"fhecej[efj_cWbgkWb_joe\b_\[WdZ
fh[l[djYecfb_YWj_edi$
B[l[be\;l_Z[dY[3??X

Discussion of Evidence

&WJEFODF
GSPN
NVMUJQMF
TUVEJFT
SFWFBMT
UIBU
QTZDIPMPHJDBM
EJTUSFTT
JT
QSFWBMFOU
GPMMPXJOH
DSFBUJPO
PG
BO

H ; 9 E C C ; D : 7J ? E D I

PTUPNZ
SFTVMUJOH
JO
JNQBJSFE
CPEZ
JNBHF
BOE
TFMG
FTUFFN
BOE
EJNJOJTIFE
RVBMJUZ
PG
MJGF
(Gooszen et al.,

2000; Holzer et al., 2005; Karadag et al., 2003; Krouse et al., 2007; Ma et al., 2007; Marquis, Marrel & Jambon, 2003;
McVey, Madill & Fielding 2001; Nugent et al., 1999; Ross et al., 2007; Scarpa et al., 2004; Wu, Chau & Twinn, 2007)

5IF
BWFSBHF
QFSJPE
PG
UJNF
OFFEFE
UP
SFTPMWF
UIF
QTZDIPMPHJDBM
EJTUSFTT
QSPEVDFE
CZ
PTUPNZ
TVSHFSZ
BOE

SFTUPSF
PQUJNBM
RVBMJUZ
PG
MJGF
JT
OPU
LOPXO
CVU
FYJTUJOH
FWJEFODF
TVHHFTUT
UIBU
UIJT
QSPDFTT
SFRVJSFT


NPOUIT
PS
MPOHFS
*O
UIF
MBSHFTU
TUVEZ
PG
20-
BNPOH
QFSTPOT
MJWJOH
XJUI
BO
PTUPNZ
QVCMJTIFE
JO
UIF
QBTU

EFDBEF
.BSRVJT
.BSSFM
BOE
+BNCPO (2003)
GPVOE
UIBU
RVBMJUZ
PG
MJGF
TDPSFT
SPTF
TUFBEJMZ
EVSJOH
UIF
STU

ZFBS
GPMMPXJOH
PTUPNZ
DSFBUJPO
XJUI
B
OFX
PTUPNZ

.D7FZ
.BEJMM
BOE
'JFMEJOH
(2001)
EFTDSJCFE
QTZDIPMPHJDBM
EJTUSFTT
DIBSBDUFSJ[FE
CZ
BDVUF
JNQBJSNFOU
PG

QFSTPOBM
DPOUSPM
UIBU
QFSTJTUFE
GPS
BU
MFBTU
UISFF
NPOUIT
GPMMPXJOH
PTUPNZ
TVSHFSZ

&YJTUJOH
FWJEFODF
BMTP
SFWFBMT
UIBU
UIF
OFHBUJWF
JNQBDU
PG
BO
PTUPNZ
PO
QIZTJDBM
BOE
GVODUJPOBM
TUBUVT

QFSTJTUT
GPS
B
QFSJPE
PG
NPOUIT
UP
ZFBST
GPMMPXJOH
TUPNB
TVSHFSZ
*O
B
TZTUFNBUJD
SFWJFX
PG
TUPNBM
BOE

QFSJTUPNBM
DPNQMJDBUJPOT
4BMWBEBMFOB
(2008)
SFQPSUFE
UIBU
UIF
JODJEFODF
PG
QFSJTUPNBM
TLJO
QSPCMFNT
BU


NPOUIT
XBT

UIF
JODJEFODF
PG
QBSBTUPNBM
IFSOJB
BU

NPOUIT
XBT

BOE
B


JODJEFODF
PG
SFUSBDUJPO
BU

NPOUIT
1SJOHMF
BOE
4XBO
(2001)
GPMMPXFE

QBUJFOUT
XJUI
DPMPTUPNJFT
BOE

DPMPSFDUBM
DBODFS
GPS
POF
ZFBS
5IFZ
SFQPSUFE
UIBU
IBMG
PG
UIFJS
TVCKFDUT
SFQPSUFE
TJHOJDBOU
GBUJHVF
BU
POF

ZFBS

FYQFSJFODFE
TFWFSF
QBJO
BOE

SFRVJSFE
SFGFSSBM
UP
B
QIZTJDJBO
GPS
QIZTJDBM
QSPCMFNT
BTTPDJ
BUFE
XJUI
UIFJS
PTUPNZ
PS
BTTPDJBUFE
EJTFBTF
*O
UIFJS
TZTUFNBUJD
SFWJFX
PG
GBDUPST
BGGFDUJOH
MJGF
XJUI
BO
PT
UPNZ
#SPXO
BOE
3BOEMF
(2005)
SFQPSU
B
TUVEZ
PG

QBUJFOUT
XJUI
VSPTUPNJFT
XIP
IBE
VOEFSHPOF
PTUPNZ

TVSHFSZ
BU
MFBTU
TJY
ZFBST
QSJPS
UP
EBUB
DPMMFDUJPO

PG
SFTQPOEFOUT
SFQPSUFE
DVSSFOU
QFSJTUPNBM
TLJO

QSPCMFNT
BOE

TUBUFE
UIFZ
IBE
BQQMJFE
GPS
EJTBCJMJUZ
CFOFUT
PXJOH
UP
TUPNBSFMBUFE
QSPCMFNT
5TFOH
FU

BM


BMTP
OPUFE
UIBU

PG
B
HSPVQ
PG

TVCKFDUT
XJUI
QFSNBOFOU
DPMPTUPNJFT
IBE
EJTDPOUJOVFE
UIFJS

FNQMPZNFOU
PS
IBE
MPTU
FNQMPZNFOU
PXJOH
UP
DIBMMFOHFT
BTTPDJBUFE
XJUI
NBOBHJOH
UIFJS
PTUPNJFT

&YJTUJOH
FWJEFODF
TUSPOHMZ
TVHHFTUT
UIBU
POHPJOH
DBSF
CZ
BO
&5/
PS
PTUPNZ
OVSTF
TQFDJBMJTU
BNFMJPSBUFT

QTZDIPMPHJDBM
EJTUSFTT
BTTPDJBUFE
XJUI
BO
PTUPNZ
JNQSPWFT
RVBMJUZ
PG
MJGF
BOE
SFEVDFT
UIF
MJLFMJIPPE
PG

DPNQMJDBUJPOT
$MJFOUT
TFFL
PVU
&5/
BOE
PTUPNZ
OVSTF
TQFDJBMJTUT
XIFO
UIFZ
FYQFSJFODF
CPUI
QIZTJDBM

QSPCMFNT
BOE
QTZDIPTPDJBM
DIBMMFOHFT
BTTPDJBUFE
XJUI
UIFJS
PTUPNZ
3JDICPVSH
5IPSQF
BOE
3BQQ



TVSWFZFE

QFSTPOT
MJWJOH
XJUI
BO
PTUPNZ
UP
EFUFSNJOF
EJGDVMUJFT
FYQFSJFODFE
CZ
DMJFOUT
BGUFS
IPTQJUBM

EJTDIBSHF
3FTQPOEFOUT
SFQPSUFE
UIBU
UIFZ
QSJNBSJMZ
TPVHIU
IFMQ
GSPN
PTUPNZ
OVSTFT
XIFO
UIFZ
FYQFSJ
FODFE
QSPCMFNT
XJUI
UIFJS
PTUPNZ
PS
UIF
QFSJTUPNBM
TLJO
%VDIFTOF
FU
BM


SFUSPTQFDUJWFMZ
SFWJFXFE

NFEJDBM
SFDPSET
PG

QBUJFOUT
VOEFSHPJOH
JOUFTUJOBM
PTUPNZ
TVSHFSZ
BOE
GPVOE
UIBU
DBSF
CZ
BO
&5/
QSP

42 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

WJEFE
B
QSPUFDUJWF
FGGFDU
BHBJOTU
TUPNBM
PS
QFSJTUPNBM
DPNQMJDBUJPOT
0EET
3BUJP


$*



"
QSPTQFDUJWF
RVBTJFYQFSJNFOUBM
TUVEZ
QSPWJEFT
BEEJUJPOBM
FWJEFODF
UIBU
POHPJOH
BDDFTT
UP
BO
&5/
PS

PTUPNZ
OVSTF
TQFDJBMJTU
CPUI
FOIBODFT
RVBMJUZ
PG
MJGF
BOE
SFEVDFT
UIF
GSFRVFODZ
PG
PTUPNZ
BQQMJBODF

DIBOHFT
#PIOFOLBNQ
FU
BM
(2004)
SFQPSUFE
SFTVMUT
PG
B
QSPTQFDUJWF
DPNQBSJTPO
DPIPSU
TUVEZ
UIBU
DPN
QBSFE
UIF
JOVFODF
PG
DBSF
EFMJWFSFE
CZ
IPNF
IFBMUI
OVSTFT
UP
UFMFIFBMUI
JOUFSBDUJPOT
XJUI
BO
PTUPNZ

OVSTF
TQFDJBMJTU
'PVSUFFO
QBUJFOUT
XFSF
BTTJHOFE
UP
USBEJUJPOBM
IPNF
WJTJUT
PS
UFMFIFBMUI
WJTJUT
XJUI
UIF

PTUPNZ
OVSTF
TQFDJBMJTU
HSPVQ
BTTJHONFOU
XBT
OPU
SBOEPNJ[FE
$MJFOUT
SFDFJWJOH
UFMFIFBMUI
JOUFSBDUJPOT

XJUI
UIF
PTUPNZ
OVSTF
TQFDJBMJTU
SFQPSUFE
HSFBUFS
TBUJTGBDUJPO
XJUI
UIFJS
DBSF
IJHIFS
20-
TDPSFT
BOE
VTFE

GFXFS
PTUPNZ
QPVDIFT
UIBO
EJE
QBUJFOUT
SFDFJWJOH
USBEJUJPOBM
IPNF
WJTJUT

$PMMFDUJWFMZ
UIFTF
OEJOHT
TUSPOHMZ
TVQQPSU
UIF
OFFE
GPS
SFHVMBS
GPMMPXVQ
CZ
BO
&5/
GPS
BMM
QFSTPOT
MJWJOH

H ; 9 E C C ; D : 7J ? E D I
XJUI
BO
PTUPNZ
GPS
B
NJOJNVN
PG

NPOUIT
QPTUPQFSBUJWFMZ
BOE
BT
OFFEFE

RECOMMENDATION 18
;ZkYWj[Yb_[djWdZ\Wc_boc[cX[hijeh[Ye]d_p[Yecfb_YWj_ediW\\[Yj_d]j^[ijecWWdZf[h_ijecWbia_d$
B[l[be\;l_Z[dY[3?L

Discussion of Evidence

0TUPNZ
FEVDBUJPO
JT
JNQFSBUJWF
GPS
DMJFOUT
JO
PSEFS
UP
CF
BCMF
UP
JEFOUJGZ
UIF
TJHOT
BOE
TZNQUPNT
PG

DPNQMJDBUJPOT
&BSMZ
JEFOUJDBUJPO
BOE
OPUJDBUJPO
PG
B
IFBMUI
QSPGFTTJPOBM
BSF
JNQPSUBOU
GBDUPST
UP
SFJO
GPSDF
XIFO
UFBDIJOH
PTUPNZ
DBSF
UP
DMJFOUT
QBSUJDVMBSMZ
XIFO
B
DPNQMJDBUJPO
JT
TVTQFDUFE
*O
B
TUVEZ
CZ

)FSMVGTFO
FU
BM
(2006)
POMZ

PG
JOEJWJEVBMT
XJUI
B
EJBHOPTFE
QFSJTUPNBM
TLJO
EJTPSEFS
SFDPHOJ[FE
UIBU

UIFZ
IBE
B
TLJO
EJTPSEFS
.PTU
SFWFBMJOH
JT
UIBU

PG
UIPTF
XIP
IBE
QFSJTUPNBM
TLJO
CSFBLEPXO
EJE
OPU

SFRVFTU
IFMQ
GSPN
UIFJS
IFBMUIDBSF
QSPGFTTJPOBM

*O
B
RVBMJUBUJWF
BOE
EFTDSJQUJWF
TUVEZ
CZ
/PUUFS
BOE
#VSOBSE
(2006)

XPNFO
IBWJOH
IBE
B
QSPDUPDPMFD
UPNZ
XJUI
MPPQ
JMFPTUPNZ
XFSF
BTLFE
UP
EFTDSJCF
UIFJS
FYQFSJFODFT
BOE
QFSDFQUJPOT
'JOEJOHT
GPDVTFE
PO

QBJO
BOE
TIPDL
CPEZ
JNBHF
BOE
TFYVBMJUZ
UIF
MPPQ
JMFPTUPNZ
BOE
UIF
SPMF
PG
UIF
HFOFSBM
BOE
TQFDJBMJTU

OVSTFT
"MUIPVHI
OPU
FYQMJDJU
UIF
JNQMJDBUJPOT
UP
QSBDUJDF
GSPN
UIJT
TUVEZ
TUSPOHMZ
SFDPNNFOE
UIBU
EVS
JOH
UIF
QSFPQFSBUJWF
QFSJPE
UIF
DMJFOU
CF
FYQPTFE
UP
UIF
SFBMJUJFT
PG
UIF
TUPNB
UIBU
JT
UP
BWPJE
TIPXJOH
B

QJDUVSF
PG
B
TUPNB
UIBU
JT
OFBU
BOE
DMFBO
BOE
FBTZ
UP
NBOBHF
'PS
UIFTF
XPNFO
UIF
SFBMJUZ
XBT
GBS
GSPN
UIF

USVUI
*OBEWFSUFOUMZ
OVSTFT
DPOUSJCVUFE
UP
UIF
FYQFSJFODFE
MFWFM
PG
EJTUSFTT
BOE
MPOHUFSN
RVBMJUZ
PG
MJGF

JTTVFT
5IFTF
OFHBUJWF
FYQFSJFODFT
DBO
EFMBZ
UIF
DMJFOUT
XJMMJOHOFTT
UP
FOHBHF
JO
TFMGDBSF
XIJDI
JNQBDUT

UIF
FBSMZ
SFDPHOJUJPO
PG
DPNQMJDBUJPOT
/VSTFT
BSF
FODPVSBHFE
UP
TFF
MJGF
UISPVHI
UIF
FZFT
PG
UIF
XPNFO

BMM
DMJFOUT

BT
UIFZ
QBTT
BMPOH
UIF
USBKFDUPSZ
PG
TVSHFSZ
BOE
SFDPWFSZ
(Notter & Burnard, 2006)

*O
B
TUVEZ
DPOEVDUFE
POF
UP
GPVS
NPOUIT
BGUFS
TVSHFSZ
CZ
.D,FO[JF
FU
BM
(2006)

PG
DMJFOUT
GPVOE
UIF

EJTQPTBM
PG
VTFE
PTUPNZ
TZTUFNT
UIF
NPTU
EJGDVMU
QBSU
PG
UIFJS
QPVDI
DIBOHF
BOE
UIF
EJTQPTBM
SPVUJOF

HSFBUMZ
BGGFDUFE
UIFJS
TPDJBM
BOE
MFJTVSF
BDUJWJUJFT
0WFS

PG
QBUJFOUT
GPVOE
UIF
DMFBOJOH
PG
UIF
TUPNB
UP

CF
UIF
NPTU
UJNFDPOTVNJOH
QBSU
PG
UIF
DIBOHF
QSPDFEVSF
5IF
JNQMJDBUJPO
UP
QSBDUJDF
JT
UIF
QTZDIPMPHJ
DBM
JNQFEJNFOU
BOE
QPUFOUJBM
BWPJEBODF
CZ
UIF
DMJFOU
BUUFOEJOH
UP
UIF
GVOEBNFOUBM
OFFET
PG
UIFJS
PTUPNZ

DBSF
5IF
DIPJDF
PG
PTUPNZ
TZTUFN
GPS
FYBNQMF
B
ESBJOBCMF
SFVTBCMF
WFSTVT
B
DMPTFE
FOE
EJTQPTBCMF

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  43
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

QPVDI
TIPVME
JODMVEF
UIF
DMJFOUT
QSFGFSFODF
5IF
SBNJDBUJPOT
PG
EFGFSSJOH
DIBOHJOH
B
MFBLJOH
QPVDI
PS

BWPJEJOH
DMFBOJOH
UIF
QFSJTUPNBM
TLJO
BSF
SJTL
GBDUPST
4VDI
BDUJPOT
DBO
QSFEJTQPTF
UIF
DMJFOU
UP
NJME
TLJO

JSSJUBUJPO
XIJDI
DBO
RVJDLMZ
MFBE
UP
TFWFSF
EFSNBUJUJT

3JDICPVSH
FU
BM
(2007)
TVQQPSUT
UIF
TUSBUFHZ
PG
DMJFOUT
QSBDUJDJOH
UIF
SFNPWBM
BOE
SFBQQMJDBUJPO
PG
UIFJS

PTUPNZ
TZTUFN
JO
DPOEJUJPOT
TJNVMBUJOH
UIFJS
IPNF
FOWJSPONFOU
"HBJO
UIJT
SFJOGPSDFT
UIF
FTUBCMJTI
NFOU
PG
B
OPSNBM
CPXFM
PS
VSJOBSZ
PTUPNZ
DBSF
SPVUJOF
BOE
UIF
QSJODJQMFT
PG
GVOEBNFOUBM
JOTQFDUJPO
BOE

NBOBHFNFOU
PG
UIF
TUPNB
BOE
QFSJTUPNBM
TLJO
CZ
UIF
DMJFOU
BOE
PS
GBNJMZ
*U
JT
JNQPSUBOU
UIBU
UIF
DMJFOU

MFBSO
XIBU
UIFJS
OPSNBM
TUPNB
BOE
TLJO
QSFTFOUBUJPO
JT
TP
UIBU
DPNQBSJTPO
PG
TVTQFDUFE
QSPCMFNT
DBO
CF

JEFOUJFE
H ; 9 E C C ; D : 7J ? E D I

3JDICPVSH
FU
BM
(2007)
JEFOUJFE
UIBU
DMJFOUT
OFFE
UP
LOPX
IPX
UP
SFDPHOJ[F
BOE
USFBU
DPNNPO
QFSJTUPNBM

TLJO
QSPCMFNT
BOE
NFUIPET
GPS
QSFWFOUJOH
PEPVS

RECOMMENDATION 19
9ebeijeco_hh_]Wj_edcWoX[_cfb[c[dj[ZWiWiW\[WdZ[\\[Yj_l[c[j^eZ\ehj^[cWdW][c[dje\
Z[iY[dZ_d]ehi_]ce_ZYebeijec_[i\ehi[b[YjWZkbjYb_[dji$
B[l[be\;l_Z[dY[3???

Discussion of Evidence

$PMPTUPNZ
JSSJHBUJPO
XBT
EFNPOTUSBUFE
UP
CF
BO
FGGFDUJWF
BMUFSOBUJWF
GPS
BDIJFWJOH
DPMPTUPNZ
DPOUJOFODF

XIJDI
IBE
B
QPTJUJWF
JNQBDU
PO
UIF
20-
GPS

DBTF
SFWJFXFE
QBUJFOUT
4JHOJDBOU
JNQSPWFNFOUT
XFSF

TDPSFE
JO
SPMF
MJNJUBUJPOT
SFMBUFE
UP
QIZTJDBM
QSPCMFNT
TPDJBM
GVODUJPOJOH
FNPUJPOBM
QSPCMFNT
HFOFSBM

NFOUBM
IFBMUI
WJUBMJUZ
BOE
CPEZ
QBJO
(Karadag, Mentes & Ayaz, 2005)

5IF
DMJFOU
SFRVJSFT
BDDFTT
UP
&5/
PS
PTUPNZ
OVSTF
TQFDJBMJTUT
XIP
DBO
QSPWJEF
DMJOJDBM
BTTFTTNFOUT
BOE

UIF
TLJMMT
SFRVJSFE
UP
UFBDI
UIF
DMJFOU
DPMPTUPNZ
JSSJHBUJPO
4VQQMFNFOUBM
FEVDBUJPOBM
NBUFSJBM
BOE
QSBDUJDF

TFTTJPOT
TFSWF
BT
BEEJUJPOBM
SFTPVSDFT
UP
FOIBODF
UIF
DMJFOUT
BCJMJUZ
UP
QFSGPSN
UIF
JSSJHBUJPO
QSPDFEVSF

CFZPOE
UIF
QPTUPQFSBUJWF
IFBMJOH
QFSJPE
5IF
DPTU
PG
JSSJHBUJPO
JT
TJHOJDBOUMZ
MFTT
XIFO
DPNQBSFE
UP

EBJMZ
QPVDIJOH
NBOBHFNFOU
5IJT
NBZ
CF
BO
BUUSBDUJPO
GPS
TPNF
DMJFOUT
"O
PVUQBUJFOU
GBDJMJUZ
XJUIJO
B

IPTQJUBM
TFUUJOH
PS
DPNNVOJUZ
OVSTJOH
DBSF
TFSWJDFT
CFDPNF
B
SFTPVSDF
GPS
UIF
DMJFOU
BOE
GBNJMZ
UP
BDDFTT

BT
UIF
TLJMM
PG
JSSJHBUJOH
JT
EFWFMPQFE
BGUFS
EJTDIBSHF
PWFS
UJNF
BOE
PO
GPMMPXVQ
BT
SFRVJSFE
1FEJBUSJD
JS
SJHBUJPO
JT
OPU
B
VTVBM
QSBDUJDF
VOMFTT
GPS
EJBHOPTUJD
PS
PUIFS
QSFTDSJCFE
TQFDJBM
NBOBHFNFOU
QSPDFEVSFT

44 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Education Recommendations
RECOMMENDATION 20
Eijeco[ZkYWj_ed\ehWbbb[l[bie\^[Wbj^#YWh[fhel_Z[hii^ekbZX[Wioij[cWj_Y"Yb_[dj#Y[djh[ZfheY[ii"
fhel_Z[Z_dXej^WYWZ[c_YWdZmehafbWY[l[dk[i$
B[l[be\;l_Z[dY[3?L

Discussion of Evidence

H ; 9 E C C ; D : 7J ? E D I
3FENBO
(2004)
SFGFST
UP
TFMGNBOBHFNFOU
QSFQBSBUJPO
BT
UIF
USBJOJOH
UIBU
QFPQMF
XJUI
DISPOJD
IFBMUI

DPOEJUJPOT
OFFE
UP
CF
BCMF
UP
EFBM
XJUI
UBLJOH
NFEJDBUJPO
BOE
NBJOUBJOJOH
UIFSBQFVUJD
SFHJNFT
NBJO
UBJOJOH
FWFSZEBZ
MJGF
TVDI
BT
FNQMPZNFOU
BOE
GBNJMZ
BOE
EFBMJOH
XJUI
UIF
GVUVSF
JODMVEJOH
DIBOHJOH

MJGF
QMBOT
BOE
UIF
GSVTUSBUJPO
BOHFS
BOE
EFQSFTTJPO
Q

UIBU
BDDPNQBOJFT
B
DISPOJD
DPOEJUJPO
"O

PTUPNZ
JT
OPU
HFOFSBMMZ
MBCFMFE
BT
B
DISPOJD
DPOEJUJPO
CVU
MJWJOH
XJUI
BO
PTUPNZ
SFRVJSFT
UIBU
UIF
DMJFOU

MFBSO
NBOZ
PG
UIF
TBNF
TFMGNBOBHFNFOU
TLJMMT
)PXFWFS
NBOZ
IFBMUIDBSF
QSPWJEFST
MBDL
UIF
PTUPNZ
SFMBUFE
LOPXMFEHF
BOE
TLJMMT
UP
QSPWJEF
FEVDBUJPO
BOE
DMJOJDBM
TVQQPSU
UP
FOBCMF
DMJFOUT
UP
NBLF
JOGPSNFE

EFDJTJPOT
BDIJFWF
UIFJS
HPBMT
BOE
PWFSDPNF
CBSSJFST
UP
FGGFDUJWF
TFMG
NBOBHFNFOU

)FBMUI
DBSF
QSPWJEFST
XIP
UFBDI
BOE
TVQQPSU
DMJFOUT
XJUI
PTUPNJFT
JODMVEF
3FHJTUFSFE
1SBDUJDBM
/VSTFT

31/

BOE
3FHJTUFSFE
/VSTFT
3/

5IFJS
CBTJD
QSPGFTTJPOBM
FEVDBUJPO
UBLFO
BU
DPNNVOJUZ
DPMMFHFT
PS

VOJWFSTJUJFT
JT
HVJEFE
CZ
HMPCBM
TUBOEBSET
TFU
PVU
CZ
UIF
.JOJTUSZ
PG
5SBJOJOH
$PMMFHFT
BOE
6OJWFSTJUJFT

XXXFEVHPWPODBFOHHFOFSBMDPMMFHFQSPHTUBOIFBMUIOVSTFIUNM
XXXFEVHPWPODBFOHHFOFS
BMDPMMFHFQSPHTUBOIFBMUITVQXPSLIUNM

BOE
CZ
UIF
$PMMFHF
PG
/VSTFT
PG
0OUBSJP
XXXDOPPSH

5IFTF
TUBOEBSET
QSPWJEF
B
HFOFSBM
PWFSWJFX
PG
QSBDUJDF
PCKFDUJWFT
MFBWJOH
TQFDJD
MFBSOJOH
PCKFDUJWFT
UP

UIF
JOEJWJEVBM
FEVDBUJPOBM
JOTUJUVUJPO
5IVT
FBDI
JOTUJUVUJPO
EFUFSNJOFT
UIF
BSFBT
PG
GPDVT
BOE
UIF
UJNF

HJWFO
UP
FBDI
'PS
UIF
HFOFSBMJTU
FEVDBUJPO
BOE
QSBDUJDF
BCPVU
PTUPNJFT
BOE
PTUPNZ
DBSF
DBO
CF
MJNJUFE

UP
BOBUPNZ
BOE
QIZTJPMPHZ
XJUI
JODMBTT
EJTDVTTJPO
UISPVHI
UIF
VTF
PG
DBTF
TUVEJFT
UP
POF
UP
UXP
IPVST

QSBDUJDJOH
PO
NPEFMT
JO
UIF
MBCPSBUPSZ
PS
UP
BDUVBMMZ
DBSJOH
GPS
B
QFSTPO
XJUI
BO
PTUPNZ
EVSJOH
B
FME

QMBDFNFOU
.BOZ
OFX
HSBEVBUFT
IBWF
OFWFS
DBSFE
GPS
B
QFSTPO
MJWJOH
XJUI
BO
PTUPNZ
QSJPS
UP
TUBSUJOH
QBJE

FNQMPZNFOU
(Personal communication, Algonquin College, 2008)

"MM
BDBEFNJD
QSPHSBNT
QSFQBSJOH
OVSTFT
PS
VOSFHVMBUFE
IFBMUI
DBSF
QSPWJEFST
1FSTPOBM
4VQQPSU
8PSL
FST148

GPS
FOUSZ
UP
QSBDUJDF
TIPVME
JODMVEF
UIFPSFUJDBM
BOE
DPNQFUFODZCBTFE
PTUPNZ
NBOBHFNFOU

QSJODJQMFT
SPPUFE
JO
BO
VOEFSTUBOEJOH
PG
TFMGNBTUFSZ
UFDIOJRVFT
5IFPSFUJDBM
DPNQPOFOUT
TIPVME
CF

UBVHIU
UP
UIF
BQQSPQSJBUF
TLJMM
MFWFM
PG
UIF
SFHVMBUFE
PS
VOSFHVMBUFE
IFBMUI
DBSF
QSPWJEFS
BDDPSEJOH
UP

QSPWJEFS
TQFDJD
DPNQFUFODJFT
PVUMJOFE
JO
3FHVMBUFE
)FBMUI
1SPGFTTJPOT
"DU
5IFPSFUJDBM
DPNQPOFOUT

UBVHIU
CBTFE
PO
UIF
MFWFM
PG
UIF
IFBMUIDBSF
QSPWJEFS
3/
31/
148

DPVME
JODMVEF
TPNF
PS
BMM
PG
UIF

GPMMPXJOH
BOBUPNZ
BOE
QIZTJPMPHZ
EJTFBTF
QSPDFTTFT
MFBEJOH
UP
CPXFM
PS
CMBEEFS
EJWFSTJPO
TVSHFSZ

DPNNPO
TVSHFSJFT
MJGFTUZMF
DIBOHFT
BT
B
SFTVMU
PG
TVSHFSZ
BOE
TUSBUFHJFT
UP
BTTFTT
DMJFOUT
OFFET
GPS
JO
GPSNBUJPOBM
FNPUJPOBM
BOE
QSBDUJDBM
TVQQPSU
UP
NBYJNJ[F
UIFJS
TFMGNBTUFSZ

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  45
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

%VSJOH
PSJFOUBUJPO
UP
BMM
QSBDUJDF
FOWJSPONFOUT
JO
XIJDI
DMJFOUT
XJUI
PTUPNJFT
TFFL
PS
BSF
QSPWJEFE
XJUI

DBSF
UIF
OFX
FNQMPZFF
TIPVME
SFDFJWF
JOGPSNBUJPO
BCPVU
UIF
DBSF
PG
UIF
DMJFOU
XJUI
BO
PTUPNZ
5IJT
JO
GPSNBUJPO
TIPVME
CF
GPDVTFE
BU
IFMQJOH
UIF
DBSF
QSPWJEFS
UP
NBYJNJ[F
UIFJS
DMJFOUT
JOEJWJEVBM
DBQBDJUZ

GPS
TFMG
NBOBHFNFOU
&YQFDUBUJPOT
PG
UIF
OFX
FNQMPZFF
BOE
DMJFOU
TFMFDUJPO
NVTU
CF
BQQSPQSJBUF
UP
UIFJS

MFHBM
TDPQF
PG
QSBDUJDF
1SPHSBNT
NVTU
BEESFTT
UIF
SFTPVSDFT
OFDFTTBSZ
UP
TVQQPSU
QSBDUJDF
BOE
IPX
UP

BDDFTT
UIFTF
SFTPVSDFT
MPDBMMZ
TVDI
BT
BDDFTT
UP
DMJFOU
TVQQPSU
MJUFSBUVSF
BOE
HSPVQT
TVQQMJFT
BOE
FYQFSU

DPOTVMUBUJPO
CZ
BO
&5/

4FF
"QQFOEJY
1
GPS
SFDPNNFOEFE
FEVDBUJPOBM
QSPHSBN
DPOUFOU
GPS
TQFDJD
MFWFMT
PG
BDBEFNJD
BOE
PSJFO
UBUJPO
QSFQBSBUJPO
GPS
3FHJTUFSFE
/VSTFT
3FHJTUFSFE
1SBDUJDBM
/VSTFT
BOE
1FSTPOBM
4VQQPSU
8PSLFST

H ; 9 E C C ; D : 7J ? E D I

RECOMMENDATION 21
9edikbj;JDi_dj^[Z[l[befc[dje\eijeco[ZkYWj_edWbfhe]hWcij^WjjWh][jWffhefh_Wj[^[Wbj^#YWh[
fhel_Z[hi"Yb_[dji"\Wc_boc[cX[hiWdZYWh[]_l[hi$
B[l[be\;l_Z[dY[3?L

Discussion of Evidence

3FHJTUFSFE
/VSTFT
XIP
IPME
B
CBDDBMBVSFBUF
EFHSFF
PS
IJHIFS
BOE
DPNQMFUF
B
GPSNBM
BDDSFEJUFE
8PVOE

0TUPNZ
$POUJOFODF
BDBEFNJD
QSPHSBN
&OUFSPTUPNBM
5IFSBQZ
/VSTJOH
&EVDBUJPO
1SPHSBN
&5/&1

BSF

&OUFSPTUPNBM
5IFSBQZ
/VSTFT
&5/T

&5/T
UISPVHI
UIFJS
BEEJUJPOBM
TQFDJBMUZ
USBJOJOH
BSF
JEFBMMZ
TVJU
FE
UP
CF
TVCKFDU
NBUUFS
FYQFSUT
BOE
FEVDBUPST
GPS
PTUPNZ
FEVDBUJPOBM
QSPHSBNT
5IFTF
OVSTFT
QSBDUJDF

XJUI
BEWBODFE
LOPXMFEHF
BOE
TLJMMT
SFHBSEJOH
UIF
DBSF
BOE
UFBDIJOH
PG
DMJFOUT
XJUI
BO
PTUPNZ
PG
BMM
BHFT

BOE
BU
BMM
EFWFMPQNFOUBM
TUBHFT
4FF
"QQFOEJY
2
GPS
&SJLTPOT
4UBHFT
PG
%FWFMPQNFOU

5IFZ
QSPWJEF

EJSFDU
DMJFOU
DBSF
BOE
FEVDBUJPOBM
BOE
DPOTVMUBUJWF
TVQQPSU
UP
IFBMUIDBSF
QSPWJEFST
*O
$BOBEB
UIF
$BOB
EJBO
"TTPDJBUJPO
GPS
&OUFSPTUPNBM
5IFSBQZ
(www.caet.ca)
TFUT
UIF
FEVDBUJPOBM
BOE
QSBDUJDF
DPNQFUFODJFT

SFRVJSFE
UP
QSBDUJDF
BT
BO
&5/
BOE
UIF
$BOBEJBO
/VSTFT
"TTPDJBUJPO
TFUT
UIF
TUBOEBSE
BOE
SFRVJSFNFOUT

GPS
TQFDJBMUZ
OVSTJOH
DFSUJDBUJPO
XXXDOBBJJDDB$/"OVSTJOHDFSUJDBUJPOEFGBVMU@FBTQY


4FF
"QQFOEJY
3
GPS
SFDPHOJ[FE
&5/
FEVDBUJPOBM
QSPHSBNT

46 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Organization & Policy Recommendations

RECOMMENDATION 22
Eh]Wd_pWj_edii^ekbZkj_b_p[WYh[Z[dj_Wb[Z;JD\ehfeb_YoZ[l[befc[djWdZfhe]hWccWdW][c[dj$
B[l[be\;l_Z[dY[3?L

Discussion of Evidence

H ; 9 E C C ; D : 7J ? E D I
&5/&1T
TVDI
BT
UIF
$BOBEJBO
"TTPDJBUJPO
GPS
&OUFSPTUPNBM
5IFSBQZ
$"&5

&5/&1
BSF
BQQSPWFE
CZ

UIF
8PSME
$PVODJM
PG
&OUFSPTUPNBM
5IFSBQZ
8$&5

5IF
$"&5&5/&1
QSFQBSFT
$BOBEJBO
3FHJTUFSFE

/VSTFT
BDBEFNJDBMMZ
BOE
DMJOJDBMMZ
UP
QSBDUJDF
JO
PTUPNZ
XPVOE
BOE
DPOUJOFODF
NBOBHFNFOU
5IF
QSP
HSBN
DFOUSFT
PO
UIF
BQQMJDBUJPO
PG
LOPXMFEHF
BOE
DMJOJDBM
FYQFSUJTF
BT
DPOTVMUBOUT
BOEPS
JO
EJSFDU
DBSF

PG
DMJFOUT
XJUI
PTUPNJFT
DPNQMFY
XPVOET
BOE
JODPOUJOFODF
3FMBUFE
SPMFT
JODMVEF
DMJFOU
BOE
TUBGG
FEVDB
UJPO
BT
XFMM
BT
SFTFBSDI
QPMJDZ
EFWFMPQNFOU
BOE
BENJOJTUSBUJPO
6QPO
DPNQMFUJPO
PG
BO
JOUFSBDUJWF
PO
MJOF
NPOUI
UIFPSFUJDBM
QSPHSBN
XIJDI
JODMVEFT

IPVST
PG
DMJOJDBM
QSFDFQUPSTIJQ
VOEFS
UIF
EJSFDU

TVQFSWJTJPO
PG
BO
FYQFSU
QSBDUJUJPOFS
UIF
TVDDFTTGVM
&5/
TUVEFOU
SFDFJWFT
B
$FSUJDBUF
JO
&OUFSPTUPNBM

5IFSBQZ
/VSTJOH
5IJT
DFSUJDBUF
BMMPXT
UIF
&5/
UP
XSJUF
UIF
$BOBEJBO
/VSTFT
"TTPDJBUJPO
&5
/VSTJOH

$FSUJDBUJPO
&YBNJOBUJPO
UP
CFDPNF
B
$FSUJFE
&5/
JO
$BOBEB

RECOMMENDATION 23
7bbYb_[djim_j^eijec_[i"WdZj^[_h\Wc_b_[i"i^ekbZ^Wl[WYY[iijeYecfh[^[di_l[[ZkYWj_ed$
B[l[be\;l_Z[dY[3?L

Discussion of Evidence

$MJFOUT
IBWF
UIF
SJHIU
UP
SFDFJWF
MJGFMPOH
FYQFSU
PTUPNZ
DBSF
BOE
NBOBHFNFOU
UP
BTTJTU
UIFN
UP
BEBQU
UP
DIBOHFT

JO
MJWJOH
XJUI
BO
PTUPNZ
TFF
"QQFOEJY
4
GPS
UIF
$IBSUFS
PG
0TUPNBUFT
3JHIUT

5IF
EFTJHO
EFWFMPQNFOU
BOE

JNQMFNFOUBUJPO
PG
TVDI
QSPHSBNT
TIPVME
SFFDU
B
DPOUJOVVN
PG
DBSF
1SPHSBNT
TIPVME
CFHJO
XJUI
B
TUSVDUVSFE

DPNQSFIFOTJWF
BOE
PSHBOJ[FE
BQQSPBDI
UP
TFMGDBSF
BOE
UIF
SFDPHOJUJPO
BOE
QSFWFOUJPO
PG
DPNQMJDBUJPOT

RECOMMENDATION 24
7c[Y^Wd_icckijX[_dfbWY[\ehj^[jhWdi\[he\_d\ehcWj_edX[jm[[dYWh[i[jj_d]ije\WY_b_jWj[
Yedj_dk[Z[ZkYWj_edWdZYb_d_YWbikffehje\j^[Yb_[dj$
B[l[be\;l_Z[dY[3?L

Discussion of Evidence

1SFEPNJOBUFMZ
QPTUPQFSBUJWF
DMJFOU
DBSF
BOE
FEVDBUJPO
UBLFT
QMBDF
JO
UIF
DMJFOUT
IPNF
OVSTJOH
IPNF

TIFMUFST
QSJWBUF
SFTJEFODF
FUD

$MJFOUT
BSF
BU
SJTL
GPS
QIZTJDBM
BOE
FNPUJPOBM
DIBMMFOHFT
GPMMPXJOH
TVS

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  47
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

HFSZ
5IFSFGPSF
UIF
TFBNMFTT
FYDIBOHF
PG
JOGPSNBUJPO
CFUXFFO
IPTQJUBM
BOE
DPNNVOJUZ
SFHBSEJOH
UIF

DMJFOUT
IFBMUI
DPOEJUJPO
QPTUPQFSBUJWF
QSPHSFTT
BOE
PTUPNZ
FEVDBUJPO
JT
FTTFOUJBM
UP
FOTVSF
PQUJNBM

BEKVTUNFOU
4FF
"QQFOEJY
&
BOE
+


RECOMMENDATION 25
FhWYj_Y[i[jj_d]ickij^Wl[WYY[iijeWd_dj[hZ_iY_fb_dWhoj[Wce\ademb[Z][WXb[WdZia_bb[Z^[Wbj^
fhe\[ii_edWbijeWZZh[iigkWb_joYWh[_deijecocWdW][c[dj$
B[l[be\;l_Z[dY[3?L

Discussion of Evidence
H ; 9 E C C ; D : 7J ? E D I

3FGFS
UP
%JTDVTTJPO
PG
&WJEFODF
GPS
3FDPNNFOEBUJPO


RECOMMENDATION 26
Dkhi_d]X[ijfhWYj_Y[]k_Z[b_d[iYWdX[ikYY[ii\kbbo_cfb[c[dj[Zedbom^[h[j^[h[Wh[WZ[gkWj[
fbWdd_d]"h[iekhY[i"eh]Wd_pWj_edWbWdZWZc_d_ijhWj_l[ikffehj"Wim[bbWiWffhefh_Wj[\WY_b_jWj_ed$
Eh]Wd_pWj_edicWom_i^jeZ[l[befWfbWd\eh_cfb[c[djWj_edj^Wj_dYbkZ[i0

n7dWii[iic[dje\eh]Wd_pWj_edWbh[WZ_d[iiWdZXWhh_[hije_cfb[c[djWj_ed"jWa_d]_djeWYYekdj

beYWbY_hYkcijWdY[i$
n?dlebl[c[dje\Wbbc[cX[him^[j^[h_dWZ_h[Yjeh_dZ_h[Yjikffehj_l[\kdYj_edm^em_bb

Yedjh_Xkj[jej^[_cfb[c[djWj_edfheY[ii$
nEd]e_d]effehjkd_j_[i\ehZ_iYkii_edWdZ[ZkYWj_edjeh[_d\ehY[j^[_cfehjWdY[e\X[ijfhWYj_Y[i$

n:[Z_YWj_ede\WgkWb_[Z_dZ_l_ZkWbjefhel_Z[j^[ikffehjd[[Z[Z\ehj^[[ZkYWj_edWdZ

_cfb[c[djWj_edfheY[ii$
nEd]e_d]effehjkd_j_[i\ehZ_iYkii_edWdZ[ZkYWj_edjeh[_d\ehY[j^[_cfehjWdY[e\X[ijfhWYj_Y[i$

nEffehjkd_j_[i\ehh[[Yj_ededf[hiedWbWdZeh]Wd_pWj_edWb[nf[h_[dY[_d_cfb[c[dj_d]]k_Z[b_d[i$

 B[l[be\;l_Z[dY[3?L

Discussion of Evidence

5IF
3FHJTUFSFE
/VSTFT
"TTPDJBUJPO
PG
0OUBSJP
UISPVHI
B
QBOFM
PG
OVSTFT
SFTFBSDIFST
BOE
BENJOJTUSB

UPST

IBT
EFWFMPQFE
UIF
5PPMLJU
*NQMFNFOUBUJPO
PG
$MJOJDBM
1SBDUJDF
(VJEFMJOFT
3/"0
C

CBTFE
PO

BWBJMBCMF
FWJEFODF
UIFPSFUJDBM
QFSTQFDUJWFT
BOE
DPOTFOTVT
5IF
5PPMLJU
JT
SFDPNNFOEFE
GPS
HVJEJOH
UIF

JNQMFNFOUBUJPO
PG
UIF
3/"0
CFTU
QSBDUJDF
HVJEFMJOF
0TUPNZ
$BSF
BOE
.BOBHFNFOU
4VDDFTTGVM
JNQMF
NFOUBUJPO
PG
UIF
CFTU
QSBDUJDF
HVJEFMJOFT
SFRVJSFT
UIF
VTF
PG
B
TUSVDUVSFE
TZTUFNBUJD
QMBOOJOH
QSPDFTT

BOE
TUSPOH
MFBEFSTIJQ
GSPN
OVSTFT
XIP
BSF
BCMF
UP
USBOTGPSN
UIF
FWJEFODFCBTFE
SFDPNNFOEBUJPOT
JOUP

QPMJDJFT
BOE
QSPDFEVSFT
UIBU
JNQBDU
PO
QSBDUJDF
XJUIJO
UIF
PSHBOJ[BUJPO
5IF
3/"0
5PPMLJU
C

QSP
WJEFT
B
TUSVDUVSFE
NPEFM
GPS
JNQMFNFOUJOH
QSBDUJDF
DIBOHF
1MFBTF
SFGFS
UP
"QQFOEJY
5
GPS
B
EFTDSJQUJPO

PG
UIF
5PPMLJU

48 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
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Level of Indicator Structure Process Outcome

What you need How you go about it What happens

Organization Policy, Procedure, n Examine organizational n Organizational lead

Practice changes culture to identify selected for evidence-
barriers & supports for based practice
an evidence-based n Best Practice
practice culture to a standing committee
develop & thrive agenda item
n Review of existing n Policies, procedures
ostomy related policies, & practices reflect &
procedures & practices support best practice in
ostomy care

Documentation changes Documentation changed n Discharge & inter-

to include: agency documentation
n Discharge Information reflects UOA, suppliers,
re: local (United Ostomy client level of inde-
Association [UOA]) & pendence & identified
local product suppliers complications
n Inter-agency documen-
tation changed to
capture the degree of
client self-care inde-
pendence, and what
barriers to mastering
self-care exist (includ-
ing complications)

50 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
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Level of Indicator Structure Process Outcome

Incident/Unusual Surgical feedback n Increased use of ETN

Occurrence Reporting to include: for pre-op education &
System n Reports analyzed at stoma siting
appropriate committee n Decreased admis-
level E.g.: sion rate secondary
 Cedj^boIkh]_YWb to stomal/peristomal
Team Committee complications
 9b_[djIW\[jo9ecc_jj[[ n Increase use of
 C[Z_YWb7Zl_ieho ambulatory clinics for
Committee ongoing management/

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n Gathering of evidence ostomy presentations
for discussion with
the surgeon if this is a
repetitive problem

Provider Nurses skilled in n Provide training related Staff report increased

ostomy care to product, anatomy, ability to provide care
complications, consults
n Conduct a staff survey
pre/post

Client Maximize client Client satisfaction survey Survey results show

independence include items that focus increased client indepen-
on mastering self-care & dence & satisfaction
achieving independence,
continuity & consistency
of care

Financial Costs Money earmarked for n Staff ETN or ETN Money budgeted for:
ostomy related education consult available n ETN
n New professional staff n Orientation
receive ostomy educa- n E-Learning available
tion in orientation
n Ongoing ostomy
education

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  51
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Reference List
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Arumugam, P. J., Bevan, L., Macdonald, L., Watkins, A. J., Morgan, A. R., Beynon, J., et al. (2003). A
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Wright, J. (2008). Managing retracted stomas. Journal of Community Nursing, 22(5), 16-21.

H;<;H;D9;I

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  63
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Appendix A: Glossary of Terms

$MJOJDBM
1SBDUJDF
(VJEFMJOFT
PS
#FTU
1SBDUJDF
(VJEFMJOFT
4ZTUFNBUJDBMMZ
EFWFM
PQFE
TUBUFNFOUT
UP
BTTJTU
QSBDUJUJPOFS
BOE
DMJFOU
EFDJTJPOT
BCPVU
BQQSPQSJBUF
IFBMUIDBSF
GPS
TQFDJD

DMJOJDBM
QSBDUJDF

DJSDVNTUBODFT
(Field & Lohr, 1990)

$POTFOTVT
"
QSPDFTT
GPS
NBLJOH
QPMJDZ
EFDJTJPOT
OPU
B
TDJFOUJD
NFUIPE
GPS
DSFBUJOH
OFX

LOPXMFEHF
$POTFOTVT
EFWFMPQNFOU
NBLFT
UIF
CFTU
VTF
PG
BWBJMBCMF
JOGPSNBUJPO
CF
UIBU
TDJFOUJD

EBUB
PS
UIF
DPMMFDUJWF
XJTEPN
PG
UIF
QBSUJDJQBOUT
(Black et al., 1999)

&EVDBUJPO
3FDPNNFOEBUJPOT
4UBUFNFOUT
PG
FEVDBUJPOBM
SFRVJSFNFOUT
BOE
FEVDBUJPOBM

BQQSPBDIFTTUSBUFHJFT
GPS
UIF
JOUSPEVDUJPO
JNQMFNFOUBUJPO
BOE
TVTUBJOBCJMJUZ
PG
UIF
CFTU
QSBDUJDF

HVJEFMJOF

0SHBOJ[BUJPO
BOE
1PMJDZ
3FDPNNFOEBUJPOT
4UBUFNFOUT
PG
DPOEJUJPOT
SFRVJSFE
GPS

B
QSBDUJDF
TFUUJOH
UIBU
FOBCMFT
UIF
TVDDFTTGVM
JNQMFNFOUBUJPO
PG
UIF
CFTU
QSBDUJDF
HVJEFMJOF
5IF

DPOEJUJPOT
GPS
TVDDFTT
BSF
MBSHFMZ
UIF
SFTQPOTJCJMJUZ
PG
UIF
PSHBOJ[BUJPO
BMUIPVHI
UIFZ
NBZ
IBWF

JNQMJDBUJPOT
GPS
QPMJDZ
BU
B
CSPBEFS
HPWFSONFOU
PS
TPDJFUBM
MFWFM

1SBDUJDF
3FDPNNFOEBUJPOT
4UBUFNFOUT
PG
CFTU
QSBDUJDF
EJSFDUFE
BU
UIF
QSBDUJDF
PG

IFBMUIDBSF
QSPGFTTJPOBMT
UIBU
BSF
JEFBMMZ
FWJEFODF
CBTFE

3BOEPNJ[FE
$POUSPMMFE
5SJBMT
$MJOJDBM
USJBMT
UIBU
JOWPMWF
BU
MFBTU
POF
UFTU
USFBUNFOU

BOE
POF
DPOUSPM
USFBUNFOU
DPODVSSFOU
FOSPMMNFOU
BOE
GPMMPXVQ
PG
UIF
UFTU
BOE
DPOUSPMUSFBUFE

HSPVQT
BOE
JO
XIJDI
UIF
USFBUNFOUT
UP
CF
BENJOJTUFSFE
BSF
TFMFDUFE
CZ
B
SBOEPN
QSPDFTT

4UBLFIPMEFS
"O
JOEJWJEVBM
HSPVQ
PS
PSHBOJ[BUJPO
XJUI
B
WFTUFE
JOUFSFTU
JO
UIF
EFDJTJPOT
BOE

BDUJPOT
PG
PSHBOJ[BUJPOT
UIBU
NBZ
BUUFNQU
UP
JOVFODF
EFDJTJPOT
BOE
BDUJPOT
(Baker et al., 1999)

4UBLFIPMEFST
JODMVEF
BMM
JOEJWJEVBMT
PS
HSPVQT
XIP
XJMM
CF
EJSFDUMZ
PS
JOEJSFDUMZ
BGGFDUFE
CZ
UIF

DIBOHF
PS
TPMVUJPO
UP
UIF
QSPCMFN
7FF;D:?9;I

4ZTUFNBUJD
3FWJFX
"O
BQQMJDBUJPO
PG
B
SJHPSPVT
TDJFOUJD
BQQSPBDI
UP
UIF
QSFQBSBUJPO
PG
B

SFWJFX
BSUJDMF (National Health and Medical Research Centre, 1998)
4ZTUFNBUJD
SFWJFXT
FTUBCMJTI
XIFSF

UIF
FGGFDUT
PG
IFBMUI
DBSF
BSF
DPOTJTUFOU
BOE
SFTFBSDI
SFTVMUT
DBO
CF
BQQMJFE
BDSPTT
QPQVMBUJPOT
TFU
UJOHT
BOE
EJGGFSFODFT
JO
USFBUNFOU
FH
EPTF

BOE
XIFSF
FGGFDUT
NBZ
WBSZ
TJHOJDBOUMZ
5IF
VTF
PG

FYQMJDJU
TZTUFNBUJD
NFUIPET
JO
SFWJFXT
MJNJUT
CJBT
TZTUFNBUJD
FSSPST

BOE
SFEVDFT
DIBODF
FGGFDUT

UIVT
QSPWJEJOH
NPSF
SFMJBCMF
SFTVMUT
VQPO
XIJDI
UP
ESBX
DPODMVTJPOT
BOE
NBLF
EFDJTJPOT
(Higgins
& Green, 2008)

64 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Appendix B: Glossary of Clinical Terms

Abdominoperineal
"
QSPDFEVSF
VTJOH
BO
BCEPNJOBM
BOE
QFSJOFBM
BQQSPBDI
GPS
UIF
SFTFDUJPO
PG
SFDUBM

Resection (APR) DBODFS
5IF
QSPDFEVSF
JOWPMWFT
SFNPWBM
PG
UIF
SFDUVN
BOVT
BOE
QFSJSFDUBM
MZNQIBUJDT

Anti-Reflux Valve
"

WBMWF
JODPSQPSBUFE
JO
VSPTUPNZ
BQQMJBODFT
5IJT
WBMWF
TUPQT
UIF
VSJOF
GSPN
HPJOH
CBDL

JOUP
UIF
LJEOFZT
PODF
JU
IBT
ESBJOFE
JOUP
UIF
QPVDI

Appliance
"MTP
DBMMFE
UIF
QPVDIJOH
TZTUFN
4FF
"QQFOEJY
0
GPS
QPVDIJOH
TZTUFNT
BOE
BDDFTTPSJFT

Belts/Binders
4FF
"QQFOEJY
0
GPS
QPVDIJOH
TZTUFNT
BOE
BDDFTTPSJFT

Colectomy
&YDJTJPO
PG
QBSU
PS
BMM
PG
UIF
DPMPO

Colostomy

5IF
TVSHJDBMMZ
DPOTUSVDUFE
PQFOJOH
XIFSF
B
QPSUJPO
PG
UIF
DPMPO
JT
CSPVHIU
UISPVHI

UIF
BCEPNJOBM
XBMM
UP
JUT
TLJO
TVSGBDF
$PMPTUPNJFT
DBO
CF
GVSUIFS
EFOFE
JO
UFSNT
PG

DPOTUSVDUJPO
MPDBUJPO
BOE
QFSNBOFODF

Convexity

4VSGBDF
UIBU
JT
DVSWFE
PS
SPVOEFE
PVUXBSE
QSPWJEFT
UFOTJPO
PO
UIF
TLJO
BUUFOJOH

QFSJTUPNBM
TLJO
DPOUPVST
DBVTJOH
B
TUPNB
UP
QSPUSVEF
CFUUFS
DBO
CF
JOUFHSBUFE
QBSU
PG

UIF
CBSSJFS

PS
BEEFE
CBSSJFS
SJOHT


4FF
"QQFOEJY
0
GPS
QPVDIJOH
TZTUFNT
BOE
BDDFTTPSJFT

Crohns Disease

*OBNNBUJPO
BOE
VMDFSBUJPO
VTVBMMZ
PG
UIF
UFSNJOBM
QPSUJPO
PG
UIF
JMFVN
BOEPS

TNBMM
CPXFM

Denudement


3FE
SBX
TLJO
BOZ
TVQFSDJBM
FSPTJPO
BOE
VMDFSBUJPOT
QSPEVDFE
NFDIBOJDBMMZ
PS
DIFNJDBMMZ

Dermatitis
4FF
1FSJTUPNBM
$POUBDU
%FSNBUJUJT
BMMFSHJD
PS
JSSJUBOU



Diversion

7FF;D:?9;I

4VSHJDBM
DSFBUJPO
PG
BO
BMUFSOBUJWF
SPVUF
GPS
FGVFOU
PG
UIF
(*
USBDU
PS
PG
UIF
6SJOBSZ

5SBDU
DBO
CF
EFTDSJCFE
BT
$POUJOFOU
PS
*ODPOUJOFOU

Educational
#PPLT
NBHB[JOFT
WJEFPT
$%T
XFCTJUFT
MFBSOJOH
EFWJDFT
DPNQVUFS
TPGUXBSF

Resources

Effluent
%JTDIBSHF

VSJOF
PS
TUPPM

Electrolyte

"O
JPOJ[FE
TBMU
JO
CMPPE
UJTTVF
VJET
BOE
DFMMT
5IFTF
TBMUT
JODMVEF
TPEJVN
QPUBTTJVN

BOE
DIMPSJOF

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  65
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

End Ostomy
"O
PTUPNZ
JO
XIJDI
UIF
QSPYJNBM
DVU
FOE

Construction
PG
UIF
DPMPO
JT
GPSNFE
JOUP
B
TUPNB
BOE
UIF

EJTUBM
DPMPO
JT
FJUIFS
SFTFDUFE
PS
DMPTFE

Illustration by Nancy Bauer, HBA, HB Admin, RN, ETN. Published with permission.

Enterostomal
3FHJTUFSFE
/VSTF
XIP
IBT
BEWBODFE
LOPXMFEHF
BOE
DMJOJDBM
TLJMM
QSFQBSBUJPO
GSPN
B

Therapy Nurse SFDPHOJ[FE
FEVDBUJPOBM
DFSUJDBUF
QSPHSBN
JO
UIF
NBOBHFNFOU
PG
PTUPNJFT
XPVOE

(ETN) BOE JODPOUJOFODF

Financial Resources
(PWFSONFOU
BTTJTUBODF
JOTVSBODF
JOEVTUSJBM
TVQQPSU
BTTPDJBUJPOT

Flange
4FF
"QQFOEJY
0
GPS
QPVDIJOH
TZTUFNT
BOE
BDDFTTPSJFT

Flush Stoma
"
TUPNB
UIBU
JT
MFWFM
XJUI
UIF
TLJO
4FF
"QQFOEJY
0
GPS
QPVDIJOH
TZTUFNT

4UPNB
)FJHIU

$SPTT
4FDUJPOBM
1SPMFT



High Profile Normal Height Low Profile Flush Retracted

Illustration by Nancy Bauer, HBA, HB Admin, RN, ETN. Published with permission.
7FF;D:?9;I

Folliculitis
*OBNNBUJPO
PG
B
GPMMJDMF
PS
GPMMJDMFT
VTVBMMZ
DBVTFE
CZ
4UBQIZMPDPDDVT
"VSFVT

Granuloma

1SFTFOUT
BT
GSJBCMF
UJTTVF
VTVBMMZ
JO
TNBMM
SBJTFE
SPVOE
TIBQFT
TDBUUFSFE
BU
UIF

NVDPDVUBOFPVT
KVODUJPO
NBZ
SFTVMU
GSPN
SFUBJOFE
PS
SFBDUJWF
TVUVSF
NBUFSJBM

66 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Hartmanns
<)FOSJ
)BSUNBOO
'S
4VSHFPO
>
5IF
TVSHJDBM
SFNPWBM
PG
B
EJTFBTFE
QPSUJPO

Procedure PG
UIF
EJTUBM
DPMPO
PS
QSPYJNBM
SFDUVN
XJUI
GPSNBUJPO
PG
BO
FOE
DPMPTUPNZ
BDDPNQBOJFE

CZ
PWFSTFXJOH
PG
UIF
EJTUBM
DPMPOJD
PS
SFDUBM
SFNOBOU






5IJT
QSPDFEVSF
NBZ
CF
UIF
STU
TUBHF
PG
B
UXPQBSU
PQFSBUJPO
JO
XIJDI
BU
B
MBUFS
EBUF
UIF

DPMPTUPNZ
BOE
UIF
PWFSTFXO
SFNOBOU
BSF
SFDPOOFDUFE





5IF
)BSUNBOO
QSPDFEVSF
JT
NPTU
PGUFO
FNQMPZFE
JO
EFCJMJUBUFE
DMJFOUT
PS
JO
FNFSHFOU

DJSDVNTUBODFT
JO
XIJDI
QSJNBSZ
BOBTUPNPTJT
PS
DPNQMFUF
EJTUBM
TFHNFOU
FYDJTJPO
XPVME

OPU
CF
BQQSPQSJBUF

Illustration by Nancy Bauer, HBA, HB Admin, RN, ETN. Published with permission.

Hernia
"
QBSBTUPNBM
IFSOJB
PDDVST
BT
B
EFGFDU
JO

Peristomal or
UIF
GBTDJB
UIBU
BMMPXT
MPPQT
PG
JOUFTUJOF
UP

Parastomal QSPUSVEF
JOUP
UIF
BSFB
PG
XFBLOFTT
%VSJOH




TUPNB
DSFBUJPO
BO
PQFOJOH
JT
NBEF
JOUP
UIF


GBTDJB
UP
BMMPX
UIF
JOUFTUJOF
UP
CF
BEWBODFE
*O

TPNF
DMJFOUT
UIJT
EFGFDU
DBO
FOMBSHF
BMMPXJOH
UIF

JOUFTUJOF
UP
CVMHF
JOUP
UIF
BSFB


.BZ
CF
TVQQPSUFE
XJUI
B
XJEF
CFMU
PS
CJOEFS

PS
NBZ
SFRVJSF
TVSHJDBM
DPSSFDUJPO

Illustration by Nancy Bauer, HBA, HB Admin, RN, ETN. Published with permission.

7FF;D:?9;I
Human Resources
,OPXMFEHF
TLJMMT
TQFDJBMJ[FE
FYQFSUJTF
BOE
UBMFOUT
PG
IFBMUI
QSBDUJPOFST
(Kerzner, 2001)

Hyperplasia
&YDFTTJWF
QSPMJGFSBUJPO
PG
OPSNBM
DFMMT
JO
UIF
OPSNBM
UJTTVF
BSSBOHFNFOU
PG
BO
PSHBO

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  67
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Ileal Conduit
"
NFUIPE
PG
EJWFSUJOH
UIF
VSJOBSZ

(Urostomy)
PX
CZ
USBOTQMBOUJOH
UIF
VSFUFST


JOUP
B
QSFQBSFE
BOE JTPMBUFE


TFHNFOU
PG
UIF
JMFVN
XIJDI
JT


TVUVSFE
DMPTFE
PO
POF
FOE
5IF


PUIFS
FOE
JT
DPOOFDUFE
UP
BO


PQFOJOH
JO
UIF
BCEPNJOBM
XBMM





5IF
JMFBM
DPOEVJU
QSPDFEVSF

JT
UIF
NPTU
DPNNPO
VSPTUPNZ

5IF
QPSUJPO
PG
CPXFM
XJMM

QSPEVDF
NVDPVT



Illustration by Nancy Bauer, HBA, HB Admin, RN, ETN. Published with permission.

Ileostomy

"
TVSHJDBM
QBTTBHF
UISPVHI
UIF
BCEPNJOBM
XBMM
UISPVHI
XIJDI
B
TFHNFOU
PG
JMFVN
JT

FYUFSJPSJ[FE
"O
FOE
TUPNB
PS
MPPQ
TUPNB
NBZ
CF
DSFBUFE

Inflammatory
5IF
UFSN
GPS
B
OVNCFS
PG
DISPOJD
SFMBQTJOH
EJTFBTFT
PG
UIF
HBTUSPJOUFTUJOBM
USBDU
PG

Bowel Disease

VOLOPXO
FUJPMPHZ
4FF
6MDFSBUJWF
$PMJUJT
BOEPS
$SPIOT
%JTFBTF

Irrigation of the
1SPDFEVSF
UP
JOTUJMM
VJE
JOUP
B
GFDBM
TUPNB
UP
QSPNPUF
UIF
FNQUZJOH
PG
TUPPMT
CFGPSF
B

Colon/Large Bowel TVSHJDBM
QSPDFEVSF
PS
BT
BO
BMUFSOBUJWF
UP
QPVDIJOH
GPS
TFMFDUFE
DMJFOUT

Karaya

4FF
"QQFOEJY
0
GPS
QPVDIJOH
TZTUFNT
BOE
BDDFTTPSJFT

Loop Ostomy
6TVBMMZ
DSFBUFE
JO
UIF

Construction
USBOTWFSTF
DPMPO
-PPQ
PTUPNZ


DBO
CF
DPOTUSVDUFE
JO
UIF
TNBMM


BOE
MBSHF
CPXFM

5IJT
JT
POF
TUPNB
XJUI
UXP


PQFOJOHT
POF
EJTDIBSHFT

7FF;D:?9;I

TUPPM
UIF
TFDPOE
NVDPVT

Cross Sectional view

Illustration by Nancy Bauer, HBA, HB Admin, RN, ETN. Published with permission.

Surface view
Illustration by Nancy Bauer, HBA, HB Admin, RN, ETN. Published with permission.

68 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Mucous Fistula

5IF
EFGVODUJPOBMJ[FE
QPSUJPO
PG
UIF
JOUFTUJOF

CSPVHIU
UP
UIF
TVSGBDF
PG
UIF
TLJO

5IF
NVDPVT
TUVMB
HFOFSBMMZ
XJMM
IBWF
B
MPXFS


QSPMF
UIBO
UIF
GVODUJPOJOH
PTUPNZ

Illustration by Nancy Bauer, HBA, HB Admin, RN, ETN. Published with permission.

Mucocutaneous

5IF
KVODUJPO
CFUXFFO
UIF
TLJO
BOE
B
NVDPVT
NFNCSBOF
TVDI
BT
B
TUPNB

Junction (MCJ)

Mucocutaneous 5IF
EFUBDINFOU
PG
UIF

Separation
TUPNB
GSPN
UIF
TLJO
*U


NBZ
CF
UIF
SFTVMU
PG
QPPS


IFBMJOH
UFOTJPO
PO
UIF


CPXFM
PS
TVQFSDJBM


JOGFDUJPO

Illustration by Nancy Bauer, HBA, HB Admin, RN, ETN. Published with permission.

Obstruction
"
QBSUJBM
PS
DPNQMFUF
CMPDLBHF
PG
UIF
MBSHF
PS
TNBMM
JOUFTUJOF

(Intestinal)

Ostomy
"
TVSHJDBM
QSPDFEVSF
DSFBUJOH
BO
PQFOJOH
CFUXFFO
UIF
VSJOBSZ
PS
(*
USBDU
BOE
UIF
TLJO

7FF;D:?9;I
Ostomy Temporary
6TVBMMZ
UIF
TVSHJDBM
QMBO
JT
UP
SFDPOOFDU
UIF
JOUFTUJOF
BOE
UP
DMPTF
UIF
PTUPNZ

Ostomy Permanent


0TUPNZ
UIBU
XJMM
OFWFS
CF
DMPTFE

Ostomy Nurse
4FF
&OUFSPTUPNBM
5IFSBQZ
/VSTF

Specialist

Ostomy Visitor


"
QFSTPO
XJUI
BO
PTUPNZ
XIP
IBT
DPNQMFUFE
B
USBJOJOH
QSPHSBN
BOE
WJTJUT
QFPQMF
CFGPSF

BOEPS
BGUFS
PTUPNZ
TVSHFSZ
5IF
WJTJUPS
HJWFT
TVQQPSU
BOE
QSBDUJDBM
BEWJDF
SBUIFS
UIBO

NFEJDBM
JOGPSNBUJPO

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  69
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Organizational
0SHBOJ[BUJPOBM
IFBMUI
JOGSBTUSVDUVSF
IPTQJUBM
PVUQBUJFOU
DMJOJD
DPNNVOJUZ
DBSF

Resources TVQQMJFST
BOE
JOEVTUSZ

Peristalsis

"
QSPHSFTTJWF
XBWFMJLF
NPWFNFOU
UIBU
PDDVST
JOWPMVOUBSJMZ
JO
IPMMPX
UVCFT
PG
UIF
CPEZ

FTQFDJBMMZ
UIF
BMJNFOUBSZ
DBOBM
QSPQFMMJOH
UIF
DPOUFOUT
GPSXBSE

Peristomal

5IF
PWFSHSPXUI
PG
B
$BOEJEB
PSHBOJTN
PG
TVGDJFOU
NBHOJUVEF
UP
DBVTF
JOBNNBUJPO

Candidiasis JOGFDUJPO
PS
EJTFBTF
PO
TLJO
PG
UIF
QFSJTUPNBM
QMBOF

Peristomal Contact
"OZ
JOBNNBUJPO
PG
UIF
TLJO
CFMJFWFE
UP
CF
EVF
UP
BO
BMMFSHJD
SFBDUJPO
UP
POF
PS
NPSF

Dermatitis (Allergic) DPNQPOFOUT
PG
B
QSPEVDU
QPVDIJOH
TZTUFNT
BOEPS
BDDFTTPSJFT


Peristomal Contact


4LJO
EBNBHF
SFTVMUJOH
GSPN
DPOUBDU
XJUI
GFDBM
PS
VSJOBSZ
ESBJOBHF

Dermatitis (Irritant)

Peristomal


UP

JODIFT
Y
DN

PG
TLJO
TVSGBDF
TVSSPVOEJOH
BO
BCEPNJOBM
TUPNB

Skin/Plane

Pouch
"
XBUFSQSPPG
SFDFQUBDMF
UIBU
DPMMFDUT
FGVFOU
JF
VSJOF
PS
TUPPM


(Appliance, Bag)

Pouching Systems
$PNQPTFE
PG
B
TLJO
CBSSJFS
BOE
B
DPMMFDUJPO
EFWJDF
UP
DPMMFDU
ESBJOBHF
FGVFOU

BOE

(Ostomy Pouching QSPUFDU
UIF
TLJO
1PVDIJOH
TZTUFNT
BSF
POFQJFDF
PS
UXPQJFDF
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5IF
QPVDI

Systems) BUUBDIFT
UP
UIF
TLJO
CBSSJFS
XIJDI
BEIFSFT
UP
UIF
BCEPNFO
BOE
JT
UUFE
PWFS
BOE
BSPVOE

UIF
TUPNB
UP
DPMMFDU
TUPPM
PS
VSJOF
4FF
"QQFOEJY
0
GPS
QPVDIJOH
TZTUFNT

BOE
BDDFTTPSJFT

Proctocolectomy
4VSHJDBM
SFNPWBM
PG
UIF
DPMPO
BOE
SFDUVN

Prolapse (Stomal)

"
DPNQMJDBUJPO
PG
PTUPNZ
TVSHFSZ
SFTVMUJOH
JO
UIF

UFMFTDPQJOH
PG
UIF
CPXFM
UISPVHI
UIF
TUPNB
4UPNBM

QSPMBQTF
NBZ
WBSZ
JO
MFOHUI

7FF;D:?9;I

*U
JT
NPTU
DPNNPO
JO
USBOTWFSTF
MPPQ
PTUPNZ


DPOTUSVDUJPOT


4FF
-PPQ
0TUPNZ
$POTUSVDUJPO

Illustration by Nancy Bauer, HBA, HB Admin, RN, ETN. Published with permission.

Pseudoverrucous
8BSUMJLF
MFTJPO
JO
UIF
QFSJTUPNBM
BSFB
Lesions

70 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Pyoderma
"
SBSF
GPSN
PG
UIF
VMDFSBUJWF
PS
DMBTTJD
QSFTFOUBUJPO
PG
UIF
EJTFBTF
1SFTFOUT
BT
QVTUVMFT

Gangrenosum TVSSPVOEFE
CZ
JOBNFE
CPSEFS
XIJDI
SBQJEMZ
QSPHSFTT
UP
VMDFSBUJPOT
XJUI
B
HSBOVMBS
PS



DSVTUFE
CBTF
BOE
CMVJTI
QVSQMF
SBJTFE
FEHFT

Retraction
5IF
EJTBQQFBSJOH
PG
UIF
OPSNBM
QSPUSVTJPO
PG
UIF
TUPNB
UP
PS
CFMPX
UIF
TLJO
$BO
CF

(Retracted Stoma) JOUFSNJUUFOU

DMJFOUT
NBZ
SFQPSU
UIBU
UIF
TUPNB
EJTBQQFBST
XIFO
UIFZ
BSF
TJUUJOH
PS

XIFO
UIF
CPXFM
JT
GVODUJPOJOH


4FF
'MVTI
4UPNB

4UPNB
)FJHIU

Illustration by Nancy Bauer, HBA, HB Admin, RN, ETN. Published with permission.

Rod

"OZ
TVQQPSU
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VTFE
JO
UIF

DPOTUSVDUJPO
PG
B
MPPQ
JMFPTUPNZ
*U
JT
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VOEFS
B
MPPQ
PG
FYUFSJPSJ[FE
CPXFM
UP
NBJOUBJO

JUT
QPTJUJPO
PO
UIF
BCEPNJOBM
TVSGBDF




4FF
-PPQ
0TUPNZ
$POTUSVDUJPO

Illustration by Nancy Bauer, HBA, HB Admin, RN, ETN. Published with permission.

Social Resources
4FMGTVQQPSU
HSPVQT
OFXTMFUUFST
DPOGFSFODFT
DBNQT
GBNJMZ
TVQQPSUJWF
PUIFST

Stent

"OZ
NBUFSJBM
PS
EFWJDF
VTFE
UP
IPME
UJTTVF
JO
QMBDF

UP
NBJOUBJO
PQFO
CMPPE
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UP
QSPWJEF
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TVQQPSU

7FF;D:?9;I
GPS
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HSBGU
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&H
TVQQPSUT
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PS
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EVF
UP
FEFNB
PG
UIF
VSFUFST
BU
UIF
JOTFSUJPO
TJUFT
JOUP

UIF
JMFVN
GPMMPXJOH
UIF
GPSNBUJPO
PG
BO
JMFP
DPOEVJU

Illustration by Nancy Bauer, HBA, HB Admin, RN, ETN. Published with permission.

Stenosis

5IF
OBSSPXJOH
PS
DPOUSBDUJOH
PG
UIF
TUPNB
PDDVSSJOH
BU
UIF
TLJO
PS
GBTDJB
JNQBJSJOH
UIF

ESBJOBHF
PG
FGVFOU

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  71
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Stoma
'SPN
UIF
(SFFL
XPSE
NPVUI
TVSHJDBM
PQFOJOH
GPS
ESBJOBHF
PG
FGVFOU

Stoma Location
$PMPTUPNZ




*MFPTUPNZ

Stomach
Transverse Colostomy
Duodenum

Descending
Ascending Colostomy Jejunum
Colostomy
Ileum

Cecostomy
Sigmoidostomy
Ileostomy

Illustration by Nancy Bauer, HBA, HB Admin, RN, ETN. Published with permission.

Stomal Siting
4FMFDUJPO
PG
UIF
JEFBM
MPDBUJPO
PO
UIF
BCEPNFO
GPS
B
TUPNB
QSJPS
UP
TVSHFSZ
CZ
B
USBJOFE

(Pre-Operative) IFBMUIDBSF
QSPGFTTJPOBM
VTVBMMZ
&5/
PS
TVSHFPO
UP
IFMQ
QSFWFOU
GVUVSF
TUPNB

DPNQMJDBUJPOT
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QSPCMFNT

Stomal Therapy
4FF
&OUFSPTUPNBM
5IFSBQZ
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Nurse (STN)

Therapeutic
"
QVSQPTFGVM
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BEWBODJOH
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Relationship BOE
PVUDPNFT
PG
UIF
DMJFOU

Ulcerative Colitis

6MDFSBUFE
JOBNNBUJPO
PG
UIF
DPMPOJD
NVDPTBM
BOE
TVCNVDPTBM
MBZFST
DIBSBDUFSJ[FE
CZ

SFNJTTJPOT
BOE
FYBDFSCBUJPOT
BSFVQT


United Ostomy
"
WPMVOUFFSCBTFE
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UP
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BMM
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7FF;D:?9;I

Association HBTUSPJOUFTUJOBM
PS
VSJOBSZ
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CZ
QSPWJEJOH
FNPUJPOBM
TVQQPSU
JOTUSVDUJPOBM
BOE

of Canada JOGPSNBUJPO
TFSWJDFT
UISPVHI
UIF
NFNCFSTIJQ
UIF
GBNJMZ
BTTPDJBUFE
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BOE
UIF

HFOFSBM
QVCMJD

Urostomy
4FF
*MFBM
$POEVJU

Wound Ostomy
4FF
&OUFSPTUPNBM
5IFSBQZ
/VSTF

Continence Nurse
(WOCN)

72 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Appendix C: Guideline Development Process

5IF
3/"0
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GVOEJOH
GSPN
UIF
(PWFSONFOU
PG
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IBT
FNCBSLFE
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NVMUJ
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QSPHSBN
PG
OVSTJOH
CFTU
QSBDUJDF
HVJEFMJOF
EFWFMPQNFOU
QJMPU
JNQMFNFOUBUJPO
FWBMVBUJPO
EJTTFNJ
OBUJPO
BOE
TVQQPSU
PG
VQUBLF
0OF
PG
UIF
BSFBT
PG
FNQIBTJT
JT
PO
OVSTJOH
JOUFSWFOUJPOT
SFMBUFE
UP
PTUPNZ

DBSF
BOE
NBOBHFNFOU
5IJT
XPSL
XBT
DPOEVDUFE
JOEFQFOEFOU
PG
BOZ
CJBT
PS
JOVFODF
GSPN
UIF
0OUBSJP

(PWFSONFOU

*O
+BOVBSZ

BO
JOUFSOBUJPOBM
NVMUJEJTDJQMJOBSZ
QBOFM
PG
OVSTFT
BOE
BMMJFE
IFBMUI
QSPGFTTJPOBMT
XJUI

FYQFSUJTF
JO
QSBDUJDF
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BOE
SFTFBSDI
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PTUPNZ
DBSF
BOE
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GSPN
B
SBOHF
PG
QSBDUJDF

TFUUJOHT
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VOEFS
UIF
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PG
UIF
3/"0
5IF
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UIF
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PG
UIFJS
XPSL

BOE
DBNF
UP
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PG
UIF
CFTU
QSBDUJDF
HVJEFMJOF

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B
TFBSDI
PG
UIF
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GPS
CFTU
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SFMFWBOU
SFTFBSDI

TUVEJFT
BOE
XFCTJUFT
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CFTU
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XFSF
GPVOE
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PG
UIF

SJHPSPVT
HVJEFMJOF
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$MJOJDBM
#FTU
1SBDUJDF
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%
GPS
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UIF
TFBSDI
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BOE
PVUDPNFT

5IF
QBOFM
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FWJEFODF
TVNNBSJFT
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LFZ
BSUJDMFT
BOE
DBNF
UP
B
DPOTFOTVT
PO
UIF

CFTU
BWBJMBCMF
FWJEFODF
PO
XIJDI
UP
CBTF
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5IF
QBOFM
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JOUP
TVCKFDU
NBUUFS

FYQFSU
TVCHSPVQT
GPS
UIF
QVSQPTF
PG
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OVSTJOH
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5IJT
QSPDFTT

SFTVMUFE
JO
UIF
EFWFMPQNFOU
PG
QSBDUJDF
FEVDBUJPO
BOE
PSHBOJ[BUJPO
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QPMJDZ
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5IF

QBOFM
NFNCFST
BT
B
XIPMF
SFWJFXFE
UIF
ESBGU
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HBQT
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BOE
DBNF
UP
DPOTFOTVT
PO
B
OBM
TFU
PG
SFDPNNFOEBUJPOT

5IJT
ESBGU
XBT
TVCNJUUFE
UP
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GPS
SFWJFX
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BO
BDLOPXMFEHFNFOU

PG
UIFTF
SFWJFXFST
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PO
QBHF

PG
UIJT
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4UBLFIPMEFST
SFQSFTFOUFE
WBSJPVT
IFBMUIDBSF

QSPGFTTJPOBM
HSPVQT
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BOE
GBNJMJFT
BT
XFMM
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QSPGFTTJPOBM
BTTPDJBUJPOT
&YUFSOBM
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XFSF

QSPWJEFE
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DPNNFOU
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UP
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PWFSBMM
GFFECBDL
BOE

HFOFSBM
JNQSFTTJPOT

5IF
GFFECBDL
GSPN
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XBT
DPNQJMFE
BOE
SFWJFXFE
CZ
UIF
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QBOFM

EJTDVTTJPO
BOE

7FF;D:?9;I
DPOTFOTVT
SFTVMUFE
JO
SFWJTJPOT
UP
UIF
ESBGU
EPDVNFOU
QSJPS
UP
QVCMJDBUJPO

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  73
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Appendix D: Process for Systematic Reviews

and Search Strategy

5IF
TFBSDI
TUSBUFHZ
VUJMJ[FE
EVSJOH
UIF
EFWFMPQNFOU
PG
UIJT
HVJEFMJOF
GPDVTFE
PO
UXP
LFZ
BSFBT
0OF
XBT

B
TUSVDUVSFE
XFCTJUF
TFBSDI
UP
JEFOUJGZ
CFTU
QSBDUJDF
HVJEFMJOFT
QVCMJTIFE
PO
UIF
UPQJD
PG
PTUPNZ
DBSF
BOE

NBOBHFNFOU
BOE
UIF
TFDPOE
XBT
B
MJUFSBUVSF
SFWJFX
UP
JEFOUJGZ
QSJNBSZ
TUVEJFT
NFUB
BOBMZTFT
BOE
TZT
UFNBUJD
SFWJFXT
QVCMJTIFE
JO
UIJT
BSFB
GSPN


Part 1: Guideline Search

0OF
JOEJWJEVBM
TFBSDIFE
BO
FTUBCMJTIFE
MJTU
PG
XFCTJUFT
GPS
DPOUFOU
SFMBUFE
UP
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UPQJD
BSFB
JO
%FDFNCFS


5IJT
MJTU
PG
TJUFT
XBT
DPNQJMFE
CBTFE
PO
FYJTUJOH
LOPXMFEHF
PG
FWJEFODFCBTFE
QSBDUJDF
XFCTJUFT

LOPXO
HVJEFMJOF
EFWFMPQFST
BOE
SFDPNNFOEBUJPOT
GSPN
UIF
MJUFSBUVSF
1SFTFODF
PS
BCTFODF
PG
HVJEF
MJOFT
XBT
OPUFE
GPS
FBDI
TJUF
TFBSDIFE
BT
XFMM
BT
EBUF
TFBSDIFE
5IF
XFCTJUFT
BU
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EJE
OPU
IPVTF

HVJEFMJOFT
CVU
EJSFDUFE
UP
BOPUIFS
XFCTJUF
PS
TPVSDF
GPS
HVJEFMJOF
SFUSJFWBM
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FJUIFS
EPXO
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BWBJMBCMF
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n "HFODZ
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BOE
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n "MCFSUB
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$MJOJDBM
1SBDUJDF
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n "NFSJDBO
$PMMFHF
PG
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n "NFSJDBO
.FEJDBM
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n #BOEPMJFS
+PVSOBM
XXXNFEJDJOFPYBDVLCBOEPMJFS

n #SJUJTI
$PMVNCJB
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n #SJUJTI
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$MJOJDBM
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n $BOBEJBO
$FOUSF
GPS
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&WJEFODF
XXXDDIFOFUDIFIPNFBTQ

n $BOBEJBO
$PDISBOF
/FUXPSL
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n $BOBEJBO
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n $BOBEJBO
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PG
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n $BOBEJBO
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n $FOUFST
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n $FOUSF
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7FF;D:?9;I

n $FOUSF
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n
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n
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n
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n
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n
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74 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
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n
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n
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n
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QFSTPOBM
BSDIJWFT
UP
JEFOUJGZ
HVJEFMJOFT
OPU
QSFWJPVTMZ
GPVOE

UISPVHI
UIF
BCPWF
TFBSDI
TUSBUFHZ

5IF
TFBSDI
TUSBUFHZ
EFTDSJCFE
BCPWF
SFTVMUFE
JO
UIF
SFUSJFWBM
PG
OP
HVJEFMJOFT
PO
UIF
UPQJD
PG
PTUPNZ
DBSF

BOE
NBOBHFNFOU

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  75
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

PART 2: Literature Review

"
EBUBCBTF
TFBSDI
GPS
FYJTUJOH
FWJEFODF
SFMBUFE
UP
PTUPNZ
DBSF
BOE
NBOBHFNFOU
XBT
DPOEVDUFE
CZ
B

6OJWFSTJUZ
)FBMUI
/FUXPSL
MJCSBSJBO
"O
JOJUJBM
TFBSDI
PG
UIF
$*/")-
1TZD*OGP
.FEMJOF
BOE
&.#"4&

EBUBCBTFT
GPS
TUVEJFT
QVCMJTIFE
GSPN

UP

XBT
DPOEVDUFE
JO
+BOVBSZ

5IJT
TFBSDI
XBT

TUSVDUVSFE
UP
BOTXFS
UIF
GPMMPXJOH
DMJOJDBM
RVFTUJPOT
EFWFMPQFE
CZ
UIF
QBOFM

1. 8IBU
QIZTJDBM
BOE
QTZDIPTPDJBM
OFFET
SFRVJSF
OVSTFMFE
JOUFSWFOUJPOT
UP
QSFQBSF
UIF
OFPOBUF

QFEJBUSJD
PS
BEVMU
QPQVMBUJPOT
GPS
PTUPNZ
TVSHFSZ

a.
1SFPQFSBUJWF

b.
1PTUPQFSBUJWF

c.
'VUVSF'PMMPXVQ

2. 8IBU
OVSTFMFE
JOUFSWFOUJPOT
BSF
FGGFDUJWF
JO
JNQSPWJOH
PTUPNZ
DBSF
BOE
QFSJTUPNBM
TLJO
DBSF

FH
SFEVDJOH
EFHSFFGSFRVFODZ
PG
DPNQMJDBUJPOT
TIPSUFOJOH
IFBMJOH
UJNF

JO
OFPOBUBM
QFEJBUSJD

PS
BEVMU
QPQVMBUJPOT

3. 8IBU
OVSTFMFE
JOUFSWFOUJPOT
BSF
FGGFDUJWF
JO
QSPNPUJOH
QBUJFOU
TFMGDBSF
PG
PTUPNZ
BOE
QFSJTUPNBM


TLJO
JO
QFEJBUSJD
PS
BEVMU
QPQVMBUJPOT

4. 8IBU
OVSTFMFE
JOUFSWFOUJPOT
BSF
FGGFDUJWF
JO
NBOBHJOH
DPNQMJDBUJPOT
JO
PTUPNJFT
BOE
QFSJTUPNBM

TLJO
JO
OFPOBUBM
QFEJBUSJD
PS
BEVMU
QPQVMBUJPOT

5. 8IBU
BSF
UIF
TQFDJBM
DPOTJEFSBUJPOT
JO
DBSJOH
GPS
JOEJWJEVBMT
XJUI
PTUPNJFT
XIP
IBWF
TQFDJBM
OFFET

JODMVEJOH
CMJOEOFTT

6. 8IBU
BSF
UIF
FEVDBUJPO
OFFET
PG
OVSTFT
MPPLJOH
BGUFS
JOEJWJEVBMT
XJUI
PTUPNJFT
7. 8IBU
QBUJFOUGPDVTFE
FEVDBUJPOBM
JOUFSWFOUJPOT
BSF
FGGFDUJWF
JO
JNQSPWJOH
QIZTJDBM
BOE
QTZDIPTPDJBM

TUBUVT
PG
JOEJWJEVBMT
XJUI
PTUPNJFT

8. 8IBU
SFTPVSDFT
VTFE
CZ
OVSTFT
JO
PTUPNZ
DBSF
BSF
NPTU
FGGFDUJWF
JO
NBOBHJOH
PTUPNJFT

FH
QSPNPUJOH
IFBMJOH
SFEVDJOH
DPNQMJDBUJPOT

9. 8IBU
SFTPVSDFT
VTFE
CZ
QBUJFOUT
JO
TFMGNBOBHFE
PTUPNZ
BOE
QFSJTUPNBM
DBSF
BSF
NPTU
FGGFDUJWF
JO

NBOBHJOH
PTUPNJFT
FH
QSPNPUJOH
IFBMJOH
SFEVDJOH
DPNQMJDBUJPOT

7FF;D:?9;I

'PS
EFUBJMT
PG
UIF
TFBSDI
SFTVMUT
QMFBTF
SFGFS
UP
0TUPNZ
$BSF
BOE
.BOBHFNFOU
B
TZTUFNBUJD
SFWJFX
PG
UIF

BTTFTTNFOU
BOE
NBOBHFNFOU
PG
DPMPTUPNJFT
JMFPTUPNJFT
BOE
VSPTUPNJFT
JODMVEJOH
UIF
BTTFTTNFOU
BOE

NBOBHFNFOU
PG
QFSJPTUPNBM
TLJO
(Mayo et al., in press).

76 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Appendix E: Sample Ostomy Teaching Record

OSTOMY TEACHING RECORD

$MJFOU

"EESFTT

Before Surgery: Teaching Completed Date & Initial

%BUF
PG
TVSHFSZ

5ZQF
PG
TVSHFSZPTUPNZ

3FBTPO
GPS
TVSHFSZ

&5
/VSTF
WJTJU

4UPNB
TJUF
TFMFDUJPO
BOE
NBSLJOH

4UPNB
MPDBUJPO
BOE
BQQFBSBODF

(JWFO
UFBDIJOH
CPPLMFUT
BCPVU
TVSHFSZ

(JWFO
TBNQMFT
PG
QPVDIJOH
TZTUFN

1VSQPTF
PG
QPVDI
BOE
TLJO
CBSSJFS

,OPXMFEHF
PG
PUIFST
XJUI
BO
PTUPNZ

7JFXFE
PTUPNZ
WJEFP

After Surgery: While in Hospital Teaching Completed Date & Initial

4UPNB
TJ[F
TXFMMJOH
TISJOLBHF
BOE
BQQFBSBODF

5ZQF
PG
ESBJOBHF
XIJMF
JO
IPTQJUBM

0CTFSWFBTTJTU
XJUI
QPVDI
FNQUZJOH

*OEFQFOEFOU
XJUI
QPVDI
FNQUZJOH

0CTFSWFBTTJTU
XJUI
SFMFBTF
PG
HBT
GSPN
QPVDI

7FF;D:?9;I
*OEFQFOEFOU
XJUI
SFMFBTF
PG
HBT
GSPN
QPVDI

0CTFSWFBTTJTU
XJUI
QPVDI
BOE
TLJO
CBSSJFS
DIBOHF

%JTDVTT
PEPVS
DPOUSPM
PQUJPOT

4JHOT
PG
QPVDI
MFBLBHF
QSFWFOUJPO
BOE
USFBUNFOU


7JFXFE
PTUPNZ
WJEFP
BOE
HJWFO
UFBDIJOH
CPPLMFU
JG
OPU
EPOF
QSFPQ


8IP
UP
DBMM
JG
QSPCMFNT
PDDVS
BGUFS
EJTDIBSHF
GSPN
IPTQJUBM

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  77
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

After Surgery: Discharged Home Teaching Completed Date & Initial

5ZQF
PG
ESBJOBHF
BU
IPNF

4UPNB
TJ[F
TXFMMJOH
TISJOLBHF
BOE
BQQFBSBODF


*OEFQFOEFOU
XJUI
QPVDI
FNQUZJOH

0CTFSWFBTTJTU
XJUI
QPVDI
BOE
TLJO
CBSSJFS
DIBOHF

*OEFQFOEFOU
XJUI
QPVDI
BOE
TLJO
CBSSJFS
DIBOHF

4JHOT
PG
QPVDI
MFBLBHF
QSFWFOUJPO
BOE
USFBUNFOU


4LJO
CSFBLEPXO
QSFWFOUJPO
BOE
USFBUNFOU


"QQMJDBUJPO
JOTUSVDUJPOT

4VQQMZ
MJTUXIFSF
UP
CVZ

$BSF
PG
TVQQMJFTFNFSHFODZ
LJU

%JTDVTT
PEPVS
DPOUSPM
PQUJPOT

/VUSJUJPOEJFUBSZ
JOTUSVDUJPOT

#BUIJOH

"DUJWJUZUSBWFM

$MPUIJOH
NPEJDBUJPOT

4FYVBM
GVODUJPO
DPODFSOT

'JOBODJBM
"TTJTUBODF
"%1
%7"
1SJWBUF
*OTVSBODF
4PDJBM
"TTJTUBODF
%JTBCJMJUZ


6OJUFE
0TUPNZ
"TTPDJBUJPO
PG
$BOBEB
4VQQPSU
(SPVQ

0TUPNZ
WJTJUPS

%JTDIBSHF
JOTUSVDUJPOT

Colostomy: Teaching Completed Date & Initial

$BSF
PG
QFSJOFBM
XPVOE
JG
QSFTFOU


.VDPVT
ESBJOBHF
QFS
SFDUVN
JG
SFDUVN
MFGU
JO
QMBDF


$BSF
PG
B
NVDPVT
TUVMB
JG
QSFTFOU


$PMPTUPNZ
JSSJHBUJPO
JOGPSNBUJPO

5SJBM
PG
B
DPMPTUPNZ
JSSJHBUJPO
PQUJPOBM


7FF;D:?9;I

$POTUJQBUJPOEJBSSIFBHBT

Ileostomy: Teaching Completed Date & Initial

$BSF
PG
QFSJOFBM
XPVOE
JG
QSFTFOU


.VDPVT
ESBJOBHF
QFS
SFDUVN
JG
SFDUVN
MFGU
JO
QMBDF


4PEJVN
MPTT
BOE
SFQMBDFNFOU

1PUBTTJVN
MPTT
BOE
SFQMBDFNFOU

0CTUSVDUJPO
BOE
NBOBHFNFOU

'MVJE
JNCBMBODF
BOE
USFBUNFOU

.FEJDBUJPO

78 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Urostomy: Teaching Completed Date & Initial

$POOFDUJOH
QPVDI
UP
BEEJUJPOBM
MFH
CBH
PQUJPOBM


$POOFDUJOH
QPVDI
UP
CFETJEF
ESBJOBHF
PQUJPOBM


$BSF
PG
CFETJEF
ESBJOBHF
DPOUBJOFS
BOEPS
MFH
CBH

.VDPVT
JO
VSJOF

'MVJE
JOUBLFDSBOCFSSZ
KVJDF

6SJOBSZ
USBDU
JOGFDUJPO

6SJOF
TBNQMF
GSPN
TUPNB

/VSTFT
4JHOBUVSF
*OJUJBMT
/VSTFT
4JHOBUVSF
*OJUJBMT

Reproduced with permission from ET NOW, CarePartners, Waterloo, Ontario.

7FF;D:?9;I

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  79
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Appendix F: Sexuality Information

Intimacy and Sexuality

n
"TTFTT
UIF
DMJFOUT
QSFPQFSBUJWF
SFMBUJPOTIJQ
XJUI
UIFJS
QBSUOFS
PS
QSFWJPVT
SFMBUJPOTIJQT
UIFZ
NBZ
IBWF
IBE

n

3FBTTVSF
DMJFOUQBSUOFS
UIBU
BO
JOUJNBUF
SFMBUJPOTIJQ
DBO
SFTVNF
PODF
UIFJS
TUSFOHUI
JT
SFHBJOFE
BOE
UIFZ
IBWF

IFBMFE
GSPN
TVSHFSZ
n

3FWJFX
XJUI
UIF
DMJFOUQBSUOFS
UIF
DIBOHFT
JO
TFYVBM
GVODUJPO
UIBU
DBO
PDDVS
BT
B
SFTVMU
PG
WBSJPVT
USFBUNFOUT

FH
TVSHFSZ
SBEJBUJPO
DIFNPUIFSBQZ

n
&ODPVSBHF
DMJFOUQBSUOFS
UP
DPNNVOJDBUF
UIFJS
GFFMJOHT
XJUI
UIFJS
QBSUOFS
PS
DBSF
QSPWJEFS

n
3FNJOE
DMJFOUQBSUOFS
UIBU
UIFSF
BSF
NBOZ
XBZT
UP
FYQSFTT
UIFNTFMWFT
TFYVBMMZ

n
3FBTTVSF
UIF
DMJFOUQBSUOFS
UIBU
QIZTJDBM
DMPTFOFTT
XJMM
OPU
IBSN
UIF
TUPNB

n

*OGPSN
DMJFOU
UIBU
JU
JT
OPU
OFDFTTBSZ
UP
UFMM
PUIFST
BCPVU
IBWJOH
BO
PTUPNZ
VOMFTT
UIFZ
GFFM
UIF
SFMBUJPOTIJQ

JT
CFDPNJOH
NPSF
TFSJPVT
PS
JOUJNBUF

Client Tips for Intimate Situations

n
1MBO
TFYVBM
BDUJWJUZ
GPS
XIFO
UIF
PTUPNZ
JT
MFTT
BDUJWF

n
"WPJE
GPPET
UIBU
NBZ
JODSFBTF
HBTPEPVS
QSPEVDUJPO

n
1MBDF
EFPEPSBOU
ESPQT
JO
UIF
QPVDI

n
4FMFDU
B
QPVDI
XJUI
B
HBT
MUFS

n
$POTJEFS
QPVDIFT
UIBU
BSF
PQBRVF
PS
DPWFSFE
XJUI
B
QPVDI
DPWFS
PS
DVNNFSCVOE

n
$IBOHF
UP
B
TNBMMFS
NJOJ
QPVDI
PS
TUPNB
DBQ

n
&NQUZ
PS
DIBOHF
QPVDI
QSJPS
UP
BDUJWJUZ

n
"EE
BO
PTUPNZ
CFMU
JG
EFTJSFE

n
&OTVSF
QPVDIFT
BSF
TFDVSF
BOE
XFMM
UUJOH

n
8FBS
QFSGVNFDPMPHOF

n
8FBS
JOUJNBUF
BQQBSFM
UP
JODSFBTF
POFT
TFOTVBMJUZ
BOE
UP
DBNPVBHF
UIF
TUPNB

n
&YQFSJNFOU
XJUI
EJGGFSFOU
CVU
DPNGPSUBCMF
QPTJUJPOT

n
1MBZ
NVTJD
UP
BWPJE
IFBSJOH
QPUFOUJBMMZ
FNCBSSBTTJOH
TPVOET

n
*G
BDDJEFOUT
IBQQFO
UBML
BCPVU
GFFMJOHTFNPUJPOT
7FF;D:?9;I

Web Sites
XXXJEFBTOBDPN
XXXJOUJNBUFNPNFOUTBQQBSFMDPN
XXXNUTJOBJPODB

XXXXFJSDPNGFFTDPN
XXXNFFUBOPTUPNBUFDPN

Source: Bressmer et al. (2008) Reprinted with permission.

80 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Appendix G: Sample Assessment Form

Ostomy Assessment Record

CORE INFORMATION

4VSHFSZ
%BUF

5ZQF
PG
PTUPNZ
$PMPTUPNZ


*MFPTUPNZ


6SPTUPNZ



.VDPVT
TUVMB

0UIFS

1FSNBOFOU


5FNQPSBSZ
"QQSPYJNBUF
DMPTVSF
EBUF

&OE
TUPNB

-PPQ
TUPNB

3PE
JOTJUV
3FNPWBM
EBUF

6SJOBSZ
TUFOUT
3FNPWBM
EBUF



$BUIFUFS

LOCATION OF STOMA

Legend:

S
TUPNB

T
UVCFT

W
XPVOE

7FF;D:?9;I
MF
NVDPVT
TUVMB

BP
CPOZ
QSPNJOFODF

SF
TLJO
GPME

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  81
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

ASSESSMENT

*OJUJBM
UIF
BQQSPQSJBUF
BTTFTTNFOU
XJUI
FBDI
BQQMJBODF
DIBOHF
GPS
UIF
STU

XFFLT
PS
XIFOFWFS
B
QSPCMFN
JT
EFUFDUFE

Date:
STOMA
Size
3PVOE
NFBTVSF
VTJOH
TUPNB
NFBTVSJOH
HVJEF

0WBM
NFBTVSF
MFOHUI
BOE
XJEUI

Colour
3FE
BEFRVBUF
CMPPE
TVQQMZ

1BMF
MPX
IBFNPHMPCJO

%BSL
SFEQVSQMJTI
UJOU
JOEJDBUFT
CSVJTJOH

(SBZ
UP
CMBDL
JTDIFNJB

OP
CMPPE
TVQQMZ

Other:

Appearance
)FBMUIZ
TIJOZ
BOE
NPJTU

5BVU
FEFNBUPVT

-BDFSBUFE
TUPNB
IBT
CFFO
DVU
PS
UPSO

(SBOVMPNBT
OPEVMFT
PO
TUPNB

Protrusion
/PSNBM
CFUXFFO




DN

'MVTI
NVDPTB
MFWFM
XJUI
TLJO

3FUSBDUFE
CFMPX
MFWFM
PG
TLJO

1SPMBQTFE
HSFBUFS
UIBO

DN
JO
MFOHUI

Other:
MUCOCUTANEOUS JUNCTION
Intact
4VUVSFT
BSPVOE
TUPNB
JOUBDU

Separated

BU













PDMPDL
TUPNB
TFQBSBUFE
GSPN
TLJO

PERISTOMAL SKIN
Colour
)FBMUIZ
OP
EJGGFSFODF
GSPN
BEKBDFOU
TLJO
TVSGBDF

&SZUIFNB
SFE

#SVJTFE
QVSQMJTI
UP
ZFMMPXJTI
DPMPVS

Integrity
*OUBDU
OP
CSFBLEPXO
JO
TLJO

.BDFSBUFE
XIJUF
GSJBCMF
TLJO
UPP
NVDI
NPJTUVSF

7FF;D:?9;I

&SPTJPO
TVQFSDJBM
TLJO
EBNBHF

3BTI
BO
PVUCSFBL
PG
MFTJPOT
PO
UIF
TLJO

6MDFSBUJPO
B
XPVOE
UISPVHI
UIF
EFSNJT
MBZFS

0UIFS
Turgor
/PSNBM
TPGU
HPPE
FMBTUJDJUZ

'MBDDJE
XFBL
BOE
BCCZ

'JSN
IBSE

Predisposing &D[FNB
QTPSJBTJT

factors
Other:

82 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Date:
EFFLUENT
Stool 5FYUVSF

'PSNFE

5IJDL

1BTUZ

-PPTF

1BTTJOH
BUVT


/POGVODUJPOJOH
OPU
QBTTJOH
BUVT
PS
TUPPM

/PSNBM
PVUQVU



N-

)JHI
PVUQVU
HSFBUFS
UIBO

N-
IPVST

-PX
PVUQVU
MFTT
UIBO

N-
IPVST

Urine
$PMPVS

"NCFSTUSBXDPMPVSFE

1JOLUJOHFE

3FE

$MBSJUZ

$MFBS

$MPVEZ

4FEJNFOU

0EPVS

/POF

.JME

'PVM

/PSNBM
PVUQVU



N-
IPVST

)JHI
PVUQVU
HSFBUFS
UIBO

N-
IPVST

-PX
PVUQVU
MFTT
UIBO

N-
IPVST

PATIENTS PERCEPTION

&OHBHFTBTLJOH
RVFTUJPOT

5VSOT
BXBZ
XJUI
PTUPNZ
DIBOHF
OSTOMY APPLIANCE USED

0OF
QJFDF

5XP
QJFDF

$POWFYJUZ

1BTUFTUSJQTCBSSJFS
TFBMT

7FF;D:?9;I

4UPNB
QPXEFS

#FMU

4JHOBUVSF
*OJUJBMT
4JHOBUVSF
*OJUJBMT

4JHOBUVSF
*OJUJBMT
4JHOBUVSF
*OJUJBMT

The RNAO would like to acknowledge panel members Karen Bruton, RN, BScN(c), ETN, and Helen Fatum, RN,
BScN, ETN, for developing this assessment form.

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  83
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Appendix H: Medication and Ostomy Function

Medication Medication Ostomy General Comments
Class Type Type (for specific info see CPS)

Analgesic Acetaminophen Ileal Conduit Cloudy urine, hematuria, skin rash,

Ileostomy itching
Analgesics must not be the long
acting form for ileostomy
Diarrhea in overdose

Salicylate Ileostomy Take with meals for absorption

Avoid enteric coated due to
prolonged absorption

Colostomy Colouration of stool: pink, red may

indicate intestinal bleeding

Opiate Colostomy Monitor bowel elimination pattern

Constipation; may require stool
softeners for descending or
sigmoid colostomy
Ileostomy Thickened stool, paralytic ileus

Adrenocorticosteroid Glucocorticosteroid Peristomal skin Thinning of skin, petechiae,

hyperpigmentation, allergic
dermatitis

Antacid Note: magnesium, calcium or Ileostomy Contraindicated in bowel

aluminum products Colostomy obstruction, rectal bleeding
May cause diarrhea, constipation
Can cause discolouration or
flecked colouring in the stool
Chronic use may induce
dependency for bowel function
7FF;D:?9;I

Antibiotic Ileal Conduit Renal damage, nephrotoxicity

Ileostomy Nausea, vomiting, moderate to
Colostomy severe diarrhea
Enterocolitis, mucositis
Pseudomembraneous colitis rare
Peristomal skin rash

Antifungal Ileal Conduit Superinfection of GI tract with

Ileostomy overgrowth black fuzz on stoma
Colostomy Foul smelling stool or urine

84 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Medication Medication Ostomy General Comments

Class Type Type (for specific info see CPS)

Anticoagulant Heparin Ileal Conduit Bleeding in stool or urine

Warfarin Colostomy Diarrhea
Ileostomy Increased stomal mucosal
bleeding
Ileostomy: normal diet intake to
maintain adequate consumption
of Vitamin K; may require
prescription

Antidiarrheal Ileostomy Constipation, rash, nausea,

Colostomy vomiting, anorexia
Paralytic ileus

Antiflatulent Ileostomy Adverse reactions of no

Colostomy known clinical significance or
contraindications

Antineoplastic Due to the wide classification of

(chemotherapeutic chemotherapeutic agents, it is
agent) recommended to consult with
a Pharmacist who specializes
in oncology pharmacy and
therapeutics

Ileostomy Diarrhea, nausea, vomiting, black

Colostomy tarry stools, constipation
Dermatitis, mucositis, unusual
bleeding from stoma, yellowing
of skin

Ileal Conduit Urine colour change, hematuria

7FF;D:?9;I
Laxatives Bulk former Ileostomy Due to the variation of products,
Stool softener Colostomy check with the pharmacist for
Stimulant specific implications
Not recommended for ileostomy
except the use of bulk forming
agents in some situations
Contraindication in bowel
obstruction, ulceration, impaction,
abdominal pain. Not a high fibre
diet substitute
Long-term use causes maroon
discolouration of mucosa called
melanosis coli
Laxative dependency over time

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  85
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Medication Medication Ostomy General Comments

Class Type Type (for specific info see CPS)

Hyperosmotic Ileostomy Excessive diarrhea, abdominal

cramps, dehydration, electrolyte
imbalance

Lubricant Ileostomy Cautionary use with colostomy and

Colostomy ileostomy
Not recommended in children up
to 6 years of age and the elderly as
prone to aspiration pneumonia
Peristomal skin irritation
Interferes with ostomy system seal
around stoma

Suppository Colostomy Suppositories are not

recommended

Enema Ileostomy NEVER PERFORMED ON

ILEOSTOMY or ILEAL CONDUIT

Colostomy Little benefit for ascending and

transverse colostomies due to
pasty stool
For descending and sigmoid
colostomy, may assist to remove
residual stool or particulate matter
post diagnostic radiography
procedures
May be used to cleanse small
bowel mucous fistula using normal
saline
May be used to cleanse large bowel
mucous fistula using solution of
prescribed choice
7FF;D:?9;I

To minimize risk of intestinal

perforation use of a cone-tip for
administration is recommended

Chemical Odour Ileostomy Never use aspirin as a pouch

Control Colostomy deodorizer due to risk of mucosal
ulcerations
Read instructions carefully for
administration: oral (internal use)
or insertion into ostomy pouch
(external use)
No need for pouch deodorant, but
Ileal conduit may use diluted vinegar in bedside
drainage bag prn

86 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Medication Medication Ostomy General Comments

Class Type Type (for specific info see CPS)

Bismuth subcarbonate Can be oral or pouch insertion

compounds Oral can result in black, tarry-like
stools or constipation

Chlorophyll compounds Can be oral or pouch insertion

Oral can result in greenish, loose
stool and green stained tongue

Oral Contraceptives Ileostomy Absorbed in the most proximal

Colostomy part of the ileum (small bowel)
with good effect
Client should be instructed to
watch for any portion of the pill
in the ostomy pouch indicating
malabsorption
Clients with known short bowel
syndrome should be counseled for
alternative method

Vitamins Ileostomy Possible B12 malabsorption,

monitor
Enteric coated pills may not be
absorbed, therefore an alternative
dose form should be used

Ileal Conduit Ascorbic acid in conjunction

with sulpha medications
is contraindicated due to
crystallization in the kidney
Vitamin C may cause peristomal
irritation
Colostomy Generally vitamins may cause an
increase in fecal and urine odour

7FF;D:?9;I
and may alter the colour of the
urine

The RNAO would like to acknowledge Rob Campbell, BScPhm Manager, Ambulatory Pharmacy, London Health
Sciences Centre, for his contribution to the medication chart.

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  87
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Appendix I: Nutritional Management

Tips in Ostomy Care
Signs and symptoms of dehydration:

n
%J[[JOFTT

n
-JHIU
IFBEFEOFTT

n
'FFMJOH
PG
UIJSTU

n
%SZ
NPVUI
BOE
UPOHVF

n
3FEVDFE
VSJOF
PVUQVU

n
6SJOF
EBSL
ZFMMPX

n
'FFMJOH
PG
BHJUBUJPO
PS
SFTUMFTTOFTT

Foods that may thicken stool:

n
"QQMFTBVDF
n
1FBOVU
#VUUFS
n
#BOBOBT

n
0BUCSBO
n
4PEB
DSBDLFST
n
1BTUB

n
0BUNFBM
n
3JDF
n
#SFBE

n
1PUBUPFT
n
5BQJPDB
n
$IFFTF

n
.BSTINBMMPXT

Foods that may loosen stool:

n
"
MDPIPM
CFFS
XJOF
BOE
MJRVPS

n
#MBDL
MJDPSJDF

n
1SVOF
KVJDF


n
$IPDPMBUF

n
-FHVNFT
n
4QJDZ
'PPET

n
$BGGFJOF
DPOUBJOJOH
CFWFSBHFT
UFB
DPGGFF
DPMBT

American Dietetic Association and Dietitians of Canada, (2000)

7FF;D:?9;I

88 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Foods rich in sodium and approximate sodium content:

Item: Amount: Sodium Content:

5BCMF
TBMU

UTQ
NH

#SPUI
NM
NH

7FHFUBCMF
DPDLUBJM
NM
NH

#BDPO

TMJDF
NH

$IFEEBS
DIFFTF

P[ HN

NH

)BN

TMJDF
NH

$BOOFE
TPVQ
NM
NH

1JDLMF

NFEJVN
NH

'SP[FO
QJ[[B
HN
NH

4BVTBHF

MJOL
NH

)PU
EPH

NH

1BODBLF

NFEJVN
NH

$PUUBHF
DIFFTF
NG
NM
NH

Foods rich in potassium and approximate potassium content:

Item: Amount: Potassium Content:

#BOBOB

MBSHF
NH

"QSJDPUT
ESJFE

DVQ
NH

#VUUFSNJML
NM
NH

.JML
NG
NM
NH

0SBOHF
KVJDF
NM
NH

1FBDI
SBX

NFEJVN
NH

5PNBUP
SBX

NFEJVN
NH

#BLFE
QPUBUP

NFEJVN
NH

'SFODI
GSJFT
NFEJVN
QPSUJPO
NH

"MM
#SBO
DFSFBM

DVQ
NH

Sodium and potassium content of sports beverage:

7FF;D:?9;I



(BUPSBEF
NM
4PEJVN
NH
1PUBTTJVN
NH

(Health Canada, 2008)

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  89
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Signs and symptoms of ileostomy and colostomy blockage:

n


$SBNQJOH
BCEPNJOBM
QBJO
XJUI
XBUFSZ
PS
OP
TUPPM
PVUQVU

n


)JHI
PVUQVU
MJRVJE
TUPPM
UP
OP
TUPPM
PVUQVU

n


3FEVDFE
UP
OP
BUVT

n


/BVTFB
BOE
WPNJUJOH

n


"CEPNJOBM
EJTUFOUJPO

n


4UPNBM
TXFMMJOH
Colwell, Goldberg, & Carmel, 2004

Foods that may cause blockage and commonly avoided in

the first 68 weeks post-operatively:

n


$PBSTF
XIFBU
CSBO

n


4BVTBHF
DBTJOHT
n


/VUT

n


$IJOFTF
WFHFUBCMFT

n


%SJFE
GSVJU
n


1PQDPSO

n


'SVJU
QJUTTFFET

n


0SBOHF
NFNCSBOF

n


$FMFSZ

n


#FBO
TQSPVUT
n


3BX
NVTISPPNT

n


8IPMF
LFSOFM
DPSO
n


3BX
QJOFBQQMF

Common gas-producing foods:

n


-FHVNFT

n


$VDVNCFS
n


.FMPO

n


&HHT

n


#SPDDPMJ
n


0OJPO

n


"QQMF
TLJO
n


#FFS
n


$BCCBHF

n


-FUUVDF
n


$BSCPOBUFE
n


5VSOJQ

n


$BVMJPXFS



CFWFSBHFT
n


#SVTTFM
TQSPVUT

Common foods that may increase malodour or discolour effluent:

7FF;D:?9;I

n


(BSMJD

n


'JTI

n


"TQBSBHVT

n


&HHT

n
#FFUT

EJTDPMPVSBUJPO
PG
VSJOF
NBZ
PDDVS
DBVTJOH
B
SFEEJTI
UJOHF

90 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

General instructions for the post-operative ostomy client:

n
$IFX
GPPE
UIPSPVHIMZ

n 1PPS
UUJOH
EFOUVSFT
PS
NJTTJOH
UFFUI
NBZ
SFRVJSF
EJFU
NPEJDBUJPO
UP
FMJNJOBUF
TPNF
GPPET

UIBU
JG
OPU
DIFXFE
XFMM
NBZ
MFBE
UP
QPUFOUJBM
CMPDLBHF

n *O
UIF
JOJUJBM
QPTUPQFSBUJWF
QIBTF
QFSJTUBMTJT
NBZ
CF
JODSFBTFE
DBVTJOH
GPPE
UP
TIPX
VQ

VOEJHFTUFE
JO
UIF
PTUPNZ
CBH
5IF
DMJFOU
TIPVME
CF
SFBTTVSFE
UIBU
JO
UJNF
USBOTJU
UJNF
XJMM

SFEVDF
BOE
XJUI
QSPQFS
DIFXJOH
GPPE
TIPVME
QBSUJBMMZ
JG
OPU
GVMMZ
CF
CSPLFO
EPXO


n "WPJE
DPOTVNJOH
UPP
NVDI
PG
POF
GPPE
FTQFDJBMMZ
JG
JU
JT
B
GPPE
UIBU
NBZ
DBVTF
BO
PCTUSVDUJPO

n "GUFS

XFFLT
NPTU
DMJFOUT
DBO
SFUVSO
UP
B
OPSNBM
EJFU
)PXFWFS
JU
JT
BEWJTBCMF
UP

DPOTVNF

TNBMMFS
NFBMT
QFS
EBZ
SBUIFS
UIBO

MBSHF
NFBMT
UP
BMMPX
UIF
EJHFTUJWF
USBDU

UP
CFUUFS
EJHFTU
BOE
BCTPSC
5IJT
XPVME
CF
FTQFDJBMMZ
USVF
GPS
UIPTF
XJUI
BO
JMFPTUPNZ
$MJFOUT

XPVME
CF
BEWJTFE
UP
EFDSFBTF
UIF
FWFOJOH
NFBM
JG
TMFFQ
JT
JOUFSSVQUFE
EVF
UP
B
GVMM
BQQMJBODF

CBH
JO
UIF
NJEEMF
PG
UIF
OJHIU
PS
SFEVDF
VJE
JOUBLF
B
GFX
IPVST
CFGPSF
TMFFQ
JO
UIF
DBTF
PG
B

VSPTUPNZ
n "WPJE
VTJOH
TUSBXT
DBSCPOBUFE
CFWFSBHFT
PS
TLJQQJOH
NFBMT
BT
UIJT
NBZ
DBVTF
FYDFTT
HBT
JO

UIF
QPVDI

7FF;D:?9;I

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  91
 7FF;D:?9;I

92
Appendix J: Ostomy Teaching Flow Sheets
Ostomy Teaching Flow Sheet - URINARY STOMAS
Knowledge Goals:
$PNQMFUF
BMM
TUFQT
XJUIJO

XFFLT
QPTUPQFSBUJWFMZ
5IJT
DIBSU
XJMM
IFMQ
UIF
1BUJFOU
BOE
UIF
/VSTF
USBDL
QSPHSFTT
BOE
MFBSOJOH
OFFET
QSF
BOE
QPTU
PQFSBUJWFMZ

1BUJFOU
VOEFSTUBOEJOH
PG
UIJT
QSPDFTT

A

"CMF
UP
VOEFSTUBOEEFTDSJCF

R

3FRVJSFT
SFJOGPSDFNFOU
Unable to understand



JOEJDBUF
JO
WBSJBODF

0TUPNZ
$BSF
BOE
.BOBHFNFOU

03
%BUF
%*4$)"3(&
%BUF

Knowledge Goals Pre-Op In Home Home Home Home Home Home

Hospital Week 1 Week 2 Week 3 Week 4 Week 5 Week 6


%JTDVTTFE
GFFMJOHT
BCPVU
TVSHFSZ
BOE
PTUPNZ

H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E


3FWJFXFE
SFTPVSDFTTVQQPSU
HSPVQT


3FWJFXFE
BOBUPNZ
BOE
QIZTJPMPHZ
PG
(6
5SBDU
CFGPSFBGUFS
TVSHFSZ



3FWJFXFE
UZQF
PG
TVSHFSZ
BOE
PTUPNZ


3FWJFXFE
PTUPNZ
TVQQMJFT
BOE
IPX
UP
GBDJMJUBUF
GVOEJOH


.BOBHFNFOU
BOE
QSFWFOUJPO
PG
VSJOBSZ
PEPVS


3FWJFXFE
EJFU
BOE
VJE
SFRVJSFNFOUT


4JHOT
BOE
TZNQUPNT
PG
VSJOBSZ
USBDU
JOGFDUJPO


)PX
UP
PCUBJO
VSJOF
TQFDJNFO
JG
65*
TVTQFDUFE


.BOBHFNFOU
PG
OJHIU
ESBJOBHF
TZTUFN


$IBOHF
JO
TUPNB
TJ[F
Y

XFFLT


1FSJTUPNBM
TLJO
DPOEJUJPOT
BOE
NBOBHFNFOU


#BUIJOH
BOE
TIPXFSJOH


3FUVSO
UP
BDUJWJUZ


4PDJBMJ[JOH
SFUVSOJOH
UP
XPSLTDIPPM


5SBWFMMJOH


*OUJNBDZ
BOE
TFYVBMJUZ


%FTDSJCF
QPVDIJOH
TZTUFN
DIBOHF
SFHJNF


0UIFS
 Ostomy Teaching Flow Sheet - URINARY STOMAS - Continued
Management Procedures:
$PNQMFUF
BMM
TUFQT
XJUIJO

XFFLT
QPTUPQFSBUJWFMZ


&OUFSPTUPNBM
5IFSBQZ
/VSTF)PTQJUBM





5FMFQIPOF

Level of patient independence: D

%FQFOEFOU

A

"TTJTUBODF
3FRVJSFE
I

*OEFQFOEFOU

In-hospital:
NJOJNVN
SFRVJSFNFOU
JOEFQFOEFODF
XJUI

QSJPS
UP
EJTDIBSHF
*EFBMMZ

QSBDUJDFE
XJUI
TVQQPSU
QSJPS
UP
EJTDIBSHF

At home:
NBJOUBJOT
JOEFQFOEFODF
XJUI

HPBM
PG
JOEFQFOEFODF
XJUI

CZ
XFFL


Management Procedures Pre-Op In Home Home Home Home Home Home

Hospital Week 1 Week 2 Week 3 Week 4 Week 5 Week 6


-PPL
BUUPVDI
TUPNB



&NQUZ
QPVDI



$POOFDUEJTDPOOFDU
OJHIU
ESBJOBHF
TZTUFN


$MFBOTF
OJHIU
ESBJOBHF
TZTUFN


(BUIFSQSFQBSF
TVQQMJFT
GPS
SPVUJOF
DIBOHF


3FNPWF
QPVDIJOH
TZTUFN



$MFBOTF
TUPNB
BOE
QFSJTUPNBM
TLJO


*OTQFDU
BOE
EFTDSJCF
TUPNBM
BOE
QFSJTUPNBM
TLJO
DPOEJUJPO


3FNPWF
QFSJTUPNBM
IBJS
JG
OFDFTTBSZ


.FBTVSF
TUPNB


5SBDF
QBUUFSO
PO
CBDL
PG
BOHF
PS
NPME
BOHF
JG
VTJOH
DVUUPU


$VUNPME
PQFOJOH
JO
BOHF


"EE
CBSSJFS
SJOHT
UP
CBDL
PG
BOHF
JG
VTJOH


$IFDL
JG
TLJO
JT
DMFBO
BOE
ESZ


1MBDF
BOHF
PO
TLJO


"UUBDI
QPVDI
UP
BOHF
JG
VTJOH
QJFDF


$MPTF
UBQ


"UUBDI
PTUPNZ
CFMU
JG
VTJOH

8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ] 


%JTDBSE
VTFE
TVQQMJFT

0UIFS
0TUPNZ
$BSF
BOE
.BOBHFNFOU

93
7FF;D:?9;I
 7FF;D:?9;I

94
Ostomy Teaching Flow Sheet - FECAL STOMAS
Knowledge Goals:
$PNQMFUF
BMM
TUFQT
XJUIJO

XFFLT
QPTUPQFSBUJWFMZ

5IJT
DIBSU
XJMM
IFMQ
UIF
1BUJFOU
BOE
UIF
/VSTF
USBDL
QSPHSFTT
BOE
MFBSOJOH
OFFET
QSF
BOE
QPTUPQFSBUJWFMZ

1BUJFOU
VOEFSTUBOEJOH
PG
UIJT
QSPDFTT

A

"CMF
UP
VOEFSTUBOEEFTDSJCF

R

3FRVJSFT
SFJOGPSDFNFOU
Unable to understand



JOEJDBUF
JO
WBSJBODF

03
%BUF
%*4$)"3(&
%BUF
0TUPNZ
$BSF
BOE
.BOBHFNFOU

Knowledge Goals Pre-Op In Home Home Home Home Home Home

Hospital Week 1 Week 2 Week 3 Week 4 Week 5 Week 6


%JTDVTTFE
GFFMJOHT
BCPVU
TVSHFSZ
BOE
PTUPNZ


3FWJFXFE
SFTPVSDFTTVQQPSU
HSPVQT


3FWJFXFE
BOBUPNZ
BOE
QIZTJPMPHZ
PG
(*
5SBDU
CFGPSFBGUFS
TVSHFSZ

H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E


3FWJFXFE
UZQF
PG
TVSHFSZ
BOE
PTUPNZ


3FWJFXFE
PTUPNZ
TVQQMJFT
BOE
IPX
UP
GBDJMJUBUF
GVOEJOH


.BOBHFNFOU
BOE
QSFWFOUJPO
PG
HBT
BOE
PEPVS


3FWJFXFE
EJFU
BOE
VJE
SFRVJSFNFOU


4JHOTTZNQUPNT
PG
PCTUSVDUJPO
BOE
NBOBHFNFOU


4JHOTTZNQUPNT
PG
EJBSSIFB
BOE
EFIZESBUJPO


4JHOTTZNQUPNT
PG
DPOTUJQBUJPO


$IBOHF
JO
TUPNB
TJ[F
Y

XFFLT


1FSJTUPNBM
TLJO
DPOEJUJPOT
BOE
NBOBHFNFOU


#BUIJOH
BOE
TIPXFSJOH


3FUVSO
UP
BDUJWJUZ


4PDJBMJ[JOH
SFUVSOJOH
UP
XPSLTDIPPM


5SBWFMMJOH


*OUJNBDZ
BOE
TFYVBMJUZ


%FTDSJCF
QPVDIJOH
TZTUFN
DIBOHF
SFHJNF

0UIFS
 Ostomy Teaching Flow Sheet - FECAL STOMAS - Continued
Management Procedures:
$PNQMFUF
BMM
TUFQT
XJUIJO

XFFLT
QPTUPQFSBUJWFMZ


&OUFSPTUPNBM
5IFSBQZ
/VSTF)PTQJUBM





5FMFQIPOF

Level of patient independence: D

%FQFOEFOU

A

"TTJTUBODF
3FRVJSFE
I

*OEFQFOEFOU

In-hospital:
NJOJNVN
SFRVJSFNFOU
JOEFQFOEFODF
XJUI

QSJPS
UP
EJTDIBSHF
*EFBMMZ

QSBDUJDFE
XJUI
TVQQPSU
QSJPS
UP
EJTDIBSHF

At home:
NBJOUBJOT
JOEFQFOEFODF
XJUI

HPBM
PG
JOEFQFOEFODF
XJUI

CZ
XFFL


Management Procedures Pre-Op In Home Home Home Home Home Home

Hospital Week 1 Week 2 Week 3 Week 4 Week 5 Week 6


-PPL
BUUPVDI
TUPNB











&NQUZ
QPVDI











3FMFBTF
HBT
GSPN
QPVDI











"EE
EFPEPSBOU
ESPQT
UP
QPVDI
PQUJPOBM











(BUIFSQSFQBSF
TVQQMJFT
GPS
SPVUJOF
DIBOHF










3FNPWF
QPVDIJOH
TZTUFN











$MFBOTF
TUPNB
BOE
QFSJTUPNBM
TLJO










*OTQFDU
BOE
EFTDSJCF
TUPNBM
BOE
QFSJTUPNBM
TLJO
DPOEJUJPO










3FNPWF
QFSJTUPNBM
IBJS
JG
OFDFTTBSZ










.FBTVSF
TUPNB










5SBDF
QBUUFSO
PO
CBDL
PG
BOHF
PS
NPME
BOHF
JG
VTJOH
DVUUPU











$VUNPME
PQFOJOH
JO
BOHF










"EE
QBTUF
PS
CBSSJFS
SJOHT
UP
CBDL
PG
BOHF
JG
VTJOH











$IFDL
JG
TLJO
JT
DMFBO
BOE
ESZ










1MBDF
BOHF
PO
TLJO










"UUBDI
QPVDI
UP
BOHF
JG
VTJOH
QJFDF











$MPTF
QPVDI
UBJM
XJUI
DMJQ
PS
JOUFHSBUFE
DMPTVSF










"UUBDI
PTUPNZ
CFMU
JG
VTJOH

8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ] 


%JTDBSE
VTFE
TVQQMJFT









0UIFS








0TUPNZ
$BSF
BOE
.BOBHFNFOU

Reprinted with permission from Toronto Community Care Access Centre.

95
7FF;D:?9;I
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Acknowledgements: Toronto Central CCAC - Joanne Greco, Director, Client Services; Toronto Central CCAC - Dipti
Purbhoo, Manager, Client Services; Toronto Central CCAC - Raquel Lashley, Care Coordinator; SEHC Metro Toronto
- Maureen Cooling, RN, ET; Spectrum Health Care - Holly Murray, RN, BScN, WOCN; University Health Network -
Debra Johnston, RN, BScN, ET; University Health Network - Claudia Ganson, RN, BScN, ET; ParaMed Home Health
Care - Estrella Mercurio, RN, BScN, ET; Toronto East General Hospital - JoAnne McKeown, RN, BScN, WOCN; St.
Michaels Hospital - Jo Hoeflok, RN, BSN, MA, ET, ACNP, CGN (C), Sunnybrook Health Sciences Centre - Debbie
Miller, RN, BScN, MN, ET; Ostomy Toronto - Carol Roda.
7FF;D:?9;I

96 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Appendix K: Ontario Chapter,

United Ostomy Association of Canada

Belleville, Quinte West & Area Chapter Oshawa & District Ostomy Association
p. 613-399-3010 p. 905-665-1711, ext. 558

Brantford & District Ostomy Association United Ostomy Support Group, Ottawa Inc.
p. 519-752-5037 p. 613-447-0361

Halton Peel Counties Sarnia/Lambton Chapter

p. 905-542-2386 p. 519-344-9060

Hamilton & District Ostomy Association Stratford & District Ostomy Association
p. 905-389-8822 p. 519-273-4327

Kitchener/Waterloo Area Ostomy Chapter Sudbury & District Ostomy Association

p. 519-894-4573 p. 705-693-3847

Kawartha District Chapter UOAC Sault Ste. Marie Chapter

p. 705-292-9910 p. 705-759-4940

London & District Ostomy Association Thunder Bay (Sleeping Giant)

p. 515-641-2782 p. 807-344-7736

Niagara Ostomy Association Ostomy Toronto

p. 905-646-2228 p. 416-596-7718

North Bay Ostomy Association Windsor & District Ostomy Association

p. 705-474-8600, ext. 2065 p. 519-727-0488

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 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  101
 7FF;D:?9;I

102
Appendix M: Sample Ostomy Care Form
SURGERY EFFLUENT ALLERGIES TO PRODUCTS OVERAL ADAPTATION
Surgical procedure Stool: Yes No
Liquid Pasty Thick Formed
Surgeon Urine:
Date of surgery Clear Mucus Sanguineous
Further surgery anticipated: MEDICATIONS
Yes No Unknown PERISTOMAL SKIN (for ileostomies only) Physical Activity:
Intact Red Moist Rash No slow release tablets No lifting (over 5 lbs) /pulling/pushing
TYPE OF OSTOMY Mucocutaneous separation No enteric coated tablets for 6 weeks
Ileostomy Colostomy Other No laxatives Sexuality:
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Urostomy Interventions: Discussed N/A

End Loop SUPPLIER
Mucous fistula Hollister ConvaTec Coloplast RESOURCES
Temporary Permanent Other Ostomy teaching booklet
Unknown MUCOUS FISTULA CARE Type: Travel Tips Diet Instructions
Rod Stents (x ) Catheter Dressing daily Pouch # 1-piece 2-piece Discharge kit Ostomy Toronto
Date to D/C rod Closure type: List of retailers Resource guide

H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
FREQUENCY OF APPLIANCE CHANGE Clip Integrated Referral to ostomy visitor
By who Once/week Twice/week Flange:
Other Flat #
FUNDING Convex # Completed by (print)
ADP Form completed: Yes No INDEPENDENCE WITH CARE Pouch:
(ADP not for temporary stomas) Pouch emptying: Drainable #
Private Insurance: Yes No Independent Requires assistance Closed end #
Financial Support: DVA DIA Caregiver dependent Urinary # Signature
HIN ODSP Employer Flange/ pouch change: Urinary night set-up #
WSIB Claim # Independent Requires assistance Quantity:
Other Caregiver dependent 5 flanges 10 pouches Phone
Physical Impairments/Limitations Date
STOMA SIZE/ CONSTRUCTION ACCESSORIES
Size DIET Paste #
Protruding Regular diet (for Colo and Uro) Belt # ADDRESSOGRAPH
Retracted Flush Post ileostomy for weeks Powder #
Oval Round Hydrations fluids: Barrier rings #
Necrosis Stenosis Minimum 1.5 L/day Other
Mucosal Sloughing Minimum 2 L/day
Other Other
Reprinted with permission from Toronto Community Care Access Centre. Acknowledgements: Toronto Central CCAC - Joanne Greco, Director, Client Services; Toronto Central CCAC - Dipti Purbhoo, Man-
ager, Client Services; Toronto Central CCAC - Raquel Lashley, Care Coordinator; SEHC Metro Toronto - Maureen Cooling, RN, ET; Spectrum Health Care - Holly Murray, RN, BScN, WOCN; University Health
Network - Debra Johnston, RN, BScN, ET; University Health Network - Claudia Ganson, RN, BScN, ET; ParaMed Home Health Care - Estrella Mercurio, RN, BScN, ET; Toronto East General Hospital - JoAnne
McKeown, RN, BScN, WOCN; St. Michaels Hospital - Jo Hoeflok, RN, BSN, MA, ET, ACNP, CGN (C), Sunnybrook Health Sciences Centre - Debbie Miller, RN, BScN, MN, ET; Ostomy Toronto - Carol Roda.
 0TUPNZ
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Appendix N: Special Needs and Care Strategies

Client with Special Needs Care Strategy/Device/Learning Resource

Pediatric
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 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  103
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Appendix O: Ostomy Product List

Generic Description of Indications Contraindications/
Categories products Precautions

Pouching systems One piece skin barrier and Factors to consider in

pouch are as one selecting pouching system
Type & consistency of effluent
Two piece skin barrier and Stoma size & construction
pouch adheres or snaps Manual dexterity & visual
onto skin barrier acuity
Level of physical activity
Financial resources
Preferences

Skin barrier Made of synthetic polymers Mandatory to protect the

or natural material (karaya) to peristomal skin
protect the skin from effluent.
Can be:
Flat or convex Poorly protruding stomas:
Regular or extended wear Convex barriers may be Use convexity with
effective caution on post-
With or without tape Sensitive skin or skin operative ostomies or
allergies: parastomal hernias
Tapeless barrier or karaya
barriers may be effective

Floating, stationary or no New post-operative clients:

flange Floating barriers help to Precut barriers are not
reduce pressure and pain recommended for oval
Pre-cut or cut-to-fit or on the abdomen when stomas
moldable opening attaching the pouch to the
Available in size adapted barrier
to premature neonate and Cut to fit barrier may be
children appropriate with clients with
poor dexterity
7FF;D:?9;I

Some pediatric skin barriers Paediatric skin barriers

are available without starter have a tendency to
hole melt more rapidly; are
more flexible, and less
resistant

Pouch Various sizes including Dependent on personal choice
neonates and childrens sizes Urostomy systems have an
Drainable anti-reflux mechanism to
Closed end prevent urine backing up
High output Filters can be beneficial for
Clip, Velcro closure or spout clients with increased flatus
Clear, opaque Special adaptors required
Gas filter for high-output and urinary
pouches when connecting to
straight drainage
Filters can become
clogged when effluent
is liquid; Filters
not recommended
immediately post-op
Opaque pouches
not recommended
immediately post-op

104 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
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Generic Description of Indications Contraindications/

Categories products Precautions

Powder Powder made from skin Absorbs moisture from Not required on intact
barrier material weepy peristomal skin to persistomal skin
promote barrier adhesion
Assists in the removal of
paste
Fills mucocutaneous
separation defects

Fillers Paste* Used to fill skin creases and Most pastes contain
Strip paste uneven skin surfaces alcohol; Cautious use
Ring Decreases leakage of on denuded skin
effluent under the barrier Use alcohol-free paste
Rings: To add convexity to a barrier in premature neonates
Pre-cut
Moldable * Paste is a filler, not glue
Convex

Sealants Wipes In clients who have known Contraindicated with

Sprays sensitivity to adhesive extended-wear barriers
products Contraindicated on
Skin conditions such as denuded skin unless
eczema alcohol-free products
Skin changes due to Non-alcohol products
chemotherapy are recommended on
Prevent skin stripping premature neonates
Can be used to waterproof
the skin barrier

Adhesive removers Wipes Build up of adhesive Denuded skin

Hypersensitive skin: pain Premature neonates
with product removal

Belt Available in adult/pediatric To increase barrier stability Assure appropriate fit
sizes For clients who are Avoid tight fit

7FF;D:?9;I
physically active and for
intimate situations if needed

Hernia belt Available in different sizes Peristomal hernias Cautious use with
convexity

Deodorant Gels Reduces odour of stools in These products are for

Liquids the pouch pouch use ONLY
Deodorizes straight drainage
systems (fecal and urine)

Stoma protectors Contact sports

Hazardous working
conditions

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  105
 7FF;D:?9;I

106
Appendix P: Recommended Ostomy Educational
Program Content for Health-Care Providers
Health Care Provider Curriculum Orientation

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XJMM
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3.

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UPPMT
UP

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H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
2.

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TIPVME
CF
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5.
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6.
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a.

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PG
UIF
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BOE
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8.
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BCOPSNBM
TUPNB 9.

3FQPSU
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UP
B
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b.

3FDPHOJUJPO
PG
OPSNBM
BOE
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TUPNB
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GPS
JMFPTUPNZ
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c.

3FDPHOJUJPO
PG
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BOE
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d.

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PG
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TUPNB
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e.

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PG
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FUD
f. 5IF
SPMF
PG
UIF
&5/
3/
BOE
31/
JO
PTUPNZ
DBSF
 Health Care Provider Curriculum Orientation

3.

5IF
GPMMPXJOH
TIPVME
CF
UBVHIU
BU
UIF
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PG


BQQMJDBUJPO
#MPPNT
5BYPOPNZ

a.

4VQQPSUJOH
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PTUPNZ
b.

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c.

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PG
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d.
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f.
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PG
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g.
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REGISTERED PRACTICAL NURSE (RPN) 1.

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a.

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5IF
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PTUPNZ
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i.

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UIF
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%PDVNFOUBUJPO
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ii.

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148
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i.

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5IF
31/
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8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ] 
GPS
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a.


.BUDI
UIF
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$BSF
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107
7FF;D:?9;I
 7FF;D:?9;I

108
Health Care Provider Curriculum Orientation

JODSFBTF
JO
UIF
OFFE
GPS
31/T
UP
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XJUI



OFFET
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b.

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1SBDUJDF


a.

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PG
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i.

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Predictability JOUFHVNFOUBSZ
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PTUPNZ

H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
"VUPOPNPVT
31/
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FH

a.
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Risk of negative outcomes in
response to care
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i.

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College of Nurses of Ontario Practice
Guideline: Utilization of RNs and RPNs
4.

5IF
GPMMPXJOH
TIPVME
CF
UBVHIU
BU
B
TZOUIFTJT
MFWFM






i.

%JGGFSFOUJBUF
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TUPNB

b.
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B
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BTTFTTNFOU
PG
TUPNB
PVUQVU






i.

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PG
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TUPNB

PVUQVU
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c.

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PG
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XPVOE
TLJO






ii.

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TLJO
SFBDUJPOT






iii.

1SPQPTF
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TLJO
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iv.

1SPQPTF
UIF
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GPS
BOE
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PG

JOUFHVNFOUBSZ
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JO

PTUPNZ
DBSF
 Health Care Provider Curriculum Orientation

5. 5IF
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TIPVME
CF
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BU
BO


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MFWFM
a.

&
WBMVBUF
UIF
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PG
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PO
TUPNB
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i.

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HBT
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b.

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i.
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PG
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Registered Nurse (RN) 1. 5IF
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a.

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i.
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ii.

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College of Nurses Practice Guideline: Utilization





iii.

1SFEJDU
UIF
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of RNs and RPNs PO
UIF
SFHJPO
b.

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i.

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2. 5IF
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TIPVME
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a.

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UIF
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PG
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UP
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OFFE

8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ] 

b.

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PG
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CSPBE

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PG
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0TUPNZ
$BSF
BOE
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109
7FF;D:?9;I
 7FF;D:?9;I

110
Health Care Provider Curriculum Orientation

3. 5IF
GPMMPXJOH
TIPVME
CF
UBVHIU
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B
TZOUIFTJT

MFWFM
a.

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B
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PG
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TUPNB






i.

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TUPNB

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ii.

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PG
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0TUPNZ
$BSF
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iii.

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PG
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TUPNB

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b.

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PG
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i.
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ii.
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H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E






iii.

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TUBOEBSE
USFBUNFOU
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TLJO
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iv.

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UIF
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BOE
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PG

JOUFHVNFOUBSZ
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DBSF
4.

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TIPVME
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MFWFM
a.

5IF
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QIZTJPMPHZ
BOE
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PG
UIF

*OUFHVNFOUBSZ
TZTUFN






i.

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DMJFOU
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UIF

JOUFHVNFOUBSZ
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UP
PTUPNZ






ii.

$IPPTF
BQQSPQSJBUF
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GPS
QFSJT
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TLJO
DPOEJUJPOT
b.

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UIF
FGGFDU
PG
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PO
TUPNB
PVUQVU






i.

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EJFUBSZ
DIBOHFT
GPS
EJBSSIFB

HBT
DPOTUJQBUJPO
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Appendix Q: Eriksons Developmental Stages

CRISIS INTERVENTION & ERIKSONS DEVELOPMENTAL STAGES

Stage Crisis Common Problems Desired Outcome Interventions

Infancy Trust Vs Distrust Mother fails to bond
Father fails to join the
family
Children develop a Teach parenting skills
sense of trust when Both parents involved
caregivers provide in care
reliability, care, &
affection

Toddler Autonomy Vs Parents become over- Children need a sense Parents should
Self-Doubt controlling & do not of control over physical encourage some child
allow independence skills & independence. self-control
Success leads to Balance limits &
autonomy, failure results independence
in shame & doubt

Preschool Initiative Vs Guilt Have difficulty
playing with other
children & initiating
play
Overly competitive &
wont share
Children need to begin Role model at
asserting control over home & encourage
the environment. appropriate
Success in this stage interaction with
leads to a sense of family
purpose. Children who Teach submission
exert too much power to authority without
experience disapproval, humiliating the child
resulting in a sense of
guilt

Childhood Industry Vs Child fails to master Children need to cope Encourage a level of
Inferiority skills with new social & competence & praise
academic demands. & keep skills & tasks
Success leads to a age appropriate
sense of competence,

7FF;D:?9;I
& failure results in
inferiority

Adolescence Identity Vs Role Parents fail
Confusion to increase
responsibility &
teen fails to manage
increase in adult-like
responsibility
Fails to shift needs
from parents to peers
Teens need to develop Discussion centred
a sense of self and on negotiation &
personal identity. compromise
Teens need decision- Teen needs social
making power and interaction with peers
responsibility. Success & to be heard
leads to an ability to Introduce teen to
stay true to oneself financial & physical
responsibility &
reality of adulthood

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  111
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Stage Crisis Common Problems Desired Outcome Interventions

Young Adult Intimacy Vs Fail to form intimate Failure leads to role
Isolation relationships confusion & weak
Fail economic & sense of self;
social independence Young adults need to
form intimate, loving
relationships. Success
leads to relationships,
while failure results in
loneliness & isolation
More social
adaptation needed
as enter adult world
with adult roles &
responsibilities
Parents to advise only

Middle Adult Generativity Vs Children leave Adults need to feel Marriage counseling
Stagnation marriage collapses useful, to create & Career change
Grand-parenting nurture things that Set boundaries with
skills are poor will outlast them, their children
often accomplished by
having children

Older Adult Ego-Integrity Vs Stops participating Older adults look Encourage

Despair Anger & shame if at their life feeling volunteerism
dependent fulfillment. Success Focus on the
at this stage leads to positives in life
feelings of wisdom Family therapy

(Kandel, 1999)

Appendix R: Recognized Educational Programs

Country Website Programs

$BOBEB XXXDBFUDB

$BOBEJBO
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7FF;D:?9;I

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112 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
$BSF
BOE
.BOBHFNFOU

Appendix S: Charter of Ostomates Rights

5IJT
$IBSUFS
PG
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PG
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MJWF
B
TFMGEFUFSNJOFE

BOE
JOEFQFOEFOU
MJGF
BOE
UP
QBSUJDJQBUF
JO
BMM
EFDJTJPONBLJOH
QSPDFTTFT

*U
JT
UIF
EFDMBSFE
PCKFDUJWF
PG
UIF
*OUFSOBUJPOBM
0TUPNZ
"TTPJDBUJPO
UIBU
UIJT
$)"35&3
TIBMM
CF
SFBMJ[FE

JO
BMM
$PVOUSJFT
PG
UIF
8PSME

The Ostomate shall:

n

3FDFJWF
QSFPQFSBUJWF
DPVOTFMMJOH
UP
FOTVSF
UIBU
UIFZ
BSF
GVMMZ
BXBSF
PG
UIF
CFOFJGUT
PG
UIF

PQFSBUJPO
BOE
UIF
FTTFOUJBM
GBDUT
BCPVU
MJWJOH
XJUI
B
TUPNB

n

)BWF
B
XFMMDPOTUSVDUFE
TUPNB
QMBDFE
BU
BO
BQQSPQSJBUF
TJUF
BOE
XJUI
GVMM
BOE
QSPQFS

DPOTJEFSBUJPO
PG
UIF
DPNGPSU
PG
UIF
QBUJFOU

n


3FDFJWF
FYQFSJFODFE
BOE
QSPGFTTJPOBM
NFEJDBM
TVQQPSU
TUPNB
OVSTJOH
DBSF
BOE
QTZDIPTPDJBM

TVQQPSU
JO
UIF
QSFPQFSBUJWF
BOE
QPTUPQFSBUJWF
QFSJPE
CPUI
JO
IPTQJUBM
BOE
JO
UIFJS
DPNNVOJUZ

n

3FDFJWF
TVQQPSU
BOE
JOGPSNBUJPO
GPS
UIF
CFOFU
PG
UIF
GBNJMZ
QFSTPOBM
DBSFHJWFST
BOE
GSJFOET

UP
JODSFBTF
UIFJS
VOEFSTUBOEJOH
PG
UIF
DPOEJUJPOT
BOE
BEKVTUNFOUT
XIJDI
BSF
OFDFTTBSZ
GPS

BDIJFWJOH
B
TBUJTGBDUPSZ
TUBOEBSE
PG
MJGF
XJUI
B
TUPNB

n

3FDFJWF
GVMM
BOE
JNQBSUJBM
JOGPSNBUJPO
BCPVU
BMM
SFMFWBOU
TVQQMJFT
BOE
QSPEVDUT
BWBJMBCMF
JO

UIFJS
$PVOUSZ

n

)BWF
VOSFTUSJDUFE
BDDFTT
UP
B
WBSJFUZ
PG
BGGPSEBCMF
PTUPNZ
QSPEVDUT

n

#F
HJWFO
JOGPSNBUJPO
BCPVU
UIFJS
/BUJPOBM
0TUPNZ
"TTPDJBUJPO
BOE
UIF
TFSWJDFT
BOE
TVQQPSU

XIJDI
DBO
CF
QSPWJEFE

7FF;D:?9;I
n

#F
QSPUFDUFE
BHBJOTU
BMM
GPSNT
PG
EJTDSJNJOBUJPO

n

3FDFJWF
BTTVSBODF
UIBU
QFSTPOBM
JOGPSNBUJPO
SFHBSEJOH
UIFJS
PTUPNZ
TVSHFSZ
XJMM
CF
USFBUFE

XJUI
EJTDSFUJPO
BOE
DPOEFOUJBMJUZ
UP
NBJOUBJO
QSJWBDZ
BOE
UIBU
OP
JOGPSNBUJPO
BCPVU
UIFJS

NFEJDBM
DPOEJUJPO
XJMM
CF
EJTDMPTFE
CZ
BOZPOF
QPTTFTTJOH
UIJT
JOGPSNBUJPO
UP
BO
FOUJUZ
UIBU

FOHBHFT
JO
UIF
NBOVGBDUVSF
TBMFT
PS
EJTUSJCVUJPO
PG
PTUPNZ
PS
SFMBUFE
QSPEVDUT
OPS
TIBMM
JU
CF

EJTDMPTFE
UP
BOZ
QFSTPO
UIBU
XJMM
CFOFU
EJSFDUMZ
PS
JOEJSFDUMZ
CFDBVTF
PG
UIFJS
SFMBUJPO
UP
UIF

DPNNFSDJBM
PTUPNZ
NBSLFU
XJUIPVU
UIF
FYQSFTTFE
DPOTFOU
PG
UIF
PTUPNBUF

Issued by the IOA Coordination Committee, June 1993. Revised by World Council, June 1997, 2004, 2007.

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  113
 0TUPNZ
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Appendix T: Description of the Toolkit

#FTU
QSBDUJDF
HVJEFMJOFT
DBO
POMZ
CF
TVDDFTTGVMMZ
JNQMFNFOUFE
JG
UIFSF
BSF
BEFRVBUF
QMBOOJOH
SFTPVSDFT

PSHBOJ[BUJPOBM
BOE
BENJOJTUSBUJWF
TVQQPSU
BT
XFMM
BT
BQQSPQSJBUF
GBDJMJUBUJPO
*O
UIJT
MJHIU
3/"0

UISPVHI
B
QBOFM
PG
OVSTFT
SFTFBSDIFST
BOE
BENJOJTUSBUPST
IBT
EFWFMPQFE
UIF
5PPMLJU
*NQMFNFOUBUJPO

PG
$MJOJDBM
1SBDUJDF
(VJEFMJOFT
CBTFE
PO
BWBJMBCMF
FWJEFODF
UIFPSFUJDBM
QFSTQFDUJWFT
BOE
DPOTFOTVT
5IF

5PPMLJU
JT
SFDPNNFOEFE
GPS
HVJEJOH
UIF
JNQMFNFOUBUJPO
PG
BOZ
DMJOJDBM
QSBDUJDF
HVJEFMJOF
JO
B
IFBMUI
DBSF

PSHBOJ[BUJPO

5IF
5PPMLJU
QSPWJEFT
TUFQCZTUFQ
EJSFDUJPOT
UP
JOEJWJEVBMT
BOE
HSPVQT
JOWPMWFE
JO
QMBOOJOH
DPPSEJOBUJOH

BOE
GBDJMJUBUJOH
UIF
HVJEFMJOF
JNQMFNFOUBUJPO
4QFDJDBMMZ
UIF
5PPMLJU
BEESFTTFT
UIF
GPMMPXJOH
LFZ
TUFQT

JO
JNQMFNFOUJOH
B
HVJEFMJOF

1. *EFOUJGZJOH
B
XFMMEFWFMPQFE
FWJEFODFCBTFE
DMJOJDBM
QSBDUJDF
HVJEFMJOF

2. *EFOUJDBUJPO
BTTFTTNFOU
BOE
FOHBHFNFOU
PG
TUBLFIPMEFST

3. "TTFTTNFOU
PG
FOWJSPONFOUBM
SFBEJOFTT
GPS
HVJEFMJOF
JNQMFNFOUBUJPO

4.
*EFOUJGZJOH
BOE
QMBOOJOH
FWJEFODFCBTFE
JNQMFNFOUBUJPO
TUSBUFHJFT

5. 1MBOOJOH
BOE
JNQMFNFOUJOH
FWBMVBUJPO

6.
*EFOUJGZJOH
BOE
TFDVSJOH
SFRVJSFE
SFTPVSDFT
GPS
JNQMFNFOUBUJPO

*NQMFNFOUJOH
HVJEFMJOFT
JO
QSBDUJDF
UIBU
SFTVMU
JO
TVDDFTTGVM
QSBDUJDF
DIBOHFT
BOE
QPTJUJWF
DMJOJDBM

JNQBDU
JT
B
DPNQMFY
VOEFSUBLJOH
5IF
5PPMLJU
JT
POF
LFZ
SFTPVSDF
GPS
NBOBHJOH
UIJT
QSPDFTT
5IF

5PPMLJU
DBO
CF
EPXOMPBEFE
BU
XXXSOBPPSHCFTUQSBDUJDFT
7FF;D:?9;I

114 H ; = ? I J ; H ; :  D K H I ; I  7 I I E 9 ? 7J ? E D  E <  E D J7 H ? E
 0TUPNZ
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Dej[i

7FF;D:?9;I

 8 ; I J  F H 7 9 J ? 9 ;  = K ? : ; B ? D ; I   m m m$ h d W e $ e h ]  115
AUGUST 2009 Clinical Best Practice Guidelines

0TUPNZ
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BOE
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.BEF
QPTTJCMF
CZ
UIF
GVOEJOH
GSPN
UIF

0OUBSJP
.JOJTUSZ
PG
)FBMUI
BOE
-POH
5FSN
$BSF

ISBN-13: 978-0-920166-95-6
ISBN-10: 0-920166-95-4
 FOR THE SPINE
Clinical Best THIS IS ART
0TUPNZ
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.BOBHFNFOU






AUGUST 2009
Practice Guidelines