What To Do When There Is No Ostomy Nurse:

Care of the Ostomy Patient

Andrea Wohlenberg RN BSN CWOCN

Stony Brook University

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Upon completion of this course, the learner will be able to

• Describe in simple terms the anatomy and physiology of the digestive system and urinary system and how this impacts each different ostomy
• Explain which type of pouching system to use with a colostomy, ileostomy and urostomy
• Demonstrate the use of ostomy accessories for different types of stomas and abdominal topography
• Verbalize a plan of care for a patient with a peristomal complication and a plan of care for a patient with a stomal complication

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(Cross, Roe, & Wang, 2014;Leyk et al., 2014; Persson & Hellstrom, 2002;Smith, Loewenstein, Rozin, Sheriff, & Ubel, 2007)

The digestive process...

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What is a stoma?

• Surgically created opening between the GI tract or urinary tract and the body.
• Can be for fecal or urinary diversion
• Formed using the small or large intestine and can be loop or end stomas (Lyon & Smith, 2010)

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Types of stomas

End

• Bowel brought through the abdominal wall and sutured to the skin
• One stoma with one opening
• Ideally protrudes 2-3 cm (Carmel, Colwell & Goldberg, 2016; Lyon & Smith, 2010)

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Types of Stomas

Loop

• Loop of intestine brought through the abdominal wall, opened (but not completely) and sutured to skin
• Plastic rod or device is placed under the loop to prevent it from slipping back into the abdomen.
• One stoma with 2 openings (Carmel, Colwell & Goldberg, 2016;Lyon & Smith, 2010)

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0314-Loop Stoma with rod. Retrieved from http://www.vatainc.com/media/catalog/product/cache/1/image/9df78eab33525d08d6e5fb8d27136e95/0/3/0314_loop-stoma-with-rod-1000x1000_5.jpg

Colostomy: Fecal Diversion

• An opening into the large intestine
• Can be made in any part of the large intestine
• Ascending colon
• Transverse colon (RUQ, mid abdomen, LUQ)
• Descending colon (LLQ)
• Sigmoid colon (LLQ) (Colwell, Goldberg, & Carmel, 2004)

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Ileostomy: Fecal Diversion

• An opening into the ileum, the last part of the small intestine
• Usually located in the right lower quadrant (Carmel, Colwell & Goldberg, 2016)

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Ileal conduit/Urostomy: Urinary Diversion

• A piece of ileum is removed from the GI system, brought out through the abdominal wall, and the ureters are attached to the proximal portion of this piece.
• Usually located in the right lower quadrant
• Urine flows all the time

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Function

Colostomy

• Initially serosanguineous fluid output then flatus/liquid stool which thickens as solid food eaten
• Output consistency and frequency depends on location

Ileostomy

• Bile-like liquid output seen within 24-48 hours postoperatively
• Large amount of liquid output initially (1000-1800 ml/day or more)
• Output thickens as solid food is eaten and the small bowel adapts with decrease of output to 400-1000 ml/day (Burch, 2005;Colwell, Goldberg, & Carmel, 2004; Kwiatt & Kawata, 2013)

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Function

Urostomy

• Functions immediately—urine always flowing
• Ureteral stents are placed at time of surgery and stay in 8-12 days before removal
• Urine is blood tinged with mucus threads first 24-36 hours (Colwell, Goldberg, & Carmel, 2004; Carmel, Colwell & Goldberg, 2016)

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Stoma characteristics

Newly created stoma should be:

• Round or oval
• Red or pink
• Moist,shiny,edematous
• Size will decrease in 6-8 weeks (Lyon & Smith, 2010)

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Stomal Protrusion

• Protruding
• Above skin level: preferred

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• Flush
• Level with skin: can be a problem
• Retracted
• Below skin level: probably will be a problem (Dorman, 2009)

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Stoma measurement

• Measure with each pouch change initially then weekly until edema has subsided
• Use a measuring guide and find the hole size that fits close to the edge of the stoma where the skin and stoma meet--within ⅛ inch of stoma
• The size selected is then traced on the back of the base (Burch, 2005;Colwell, Goldberg, & Carmel, 2004; Emptying and changing the pouch, n.d.; Shultz, 2002)

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Stoma assessment

• Transparent ostomy pouch should be used postoperatively so the stoma can be visualized/monitored
• The stoma should be periodically assessed during the postoperative period for size, shape and protrusion (Carmel, Colwell & Goldberg, 2016)

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Stomal complications

Necrosis

• Stoma is dark in color (dusky, burgundy, purple, black)
• Ischemia occurs in 2-3 % of stomas and usually happens within first 24-48 hours after surgery
• Notify surgeon of necrotic stoma (Lyon & Smith, 2010; Stelton & Holmsted, 2010)

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Stomal complications

Mucocutaneous separation

• Stoma separates from skin
• Usually occurs in patients with poor nutrition,diabetes or steroid use
• Fill gap with powder or alginate dressing depending on size of wound
• Surgeon should evaluate (Carmel, Colwell & Goldberg, 2016; Stelton & Holmsted, 2010)

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Stomal complications

Prolapse

• Telescoping of intestine through stoma
• Enlarge hole in base to accommodate the stoma
• Prolapse can be reduced with application of cold for a few minutes
• URGENT if symptoms of acute abdomen, severe prolapse or bowel strangulation (Carmel, Colwell & Goldberg, 2016; Dorman, 2009; Stelton & Holmsted, 2010; Wound Ostomy and Continence Nurses Society, 2014)

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Stomal complications

Retraction

• Stoma is below skin level
• Occurs more frequently in obese patients
• Can occur when loop rod/bridge removed too soon
• Usually need convex base/pouch and often need belt (Barr, 2004; Carmel, Colwell & Goldberg, 2016; Stelton & Holmsted, 2010)

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Stomal complications

Peristomal hernia

• Defect allowing intestine to loop through fascia causing a bulge
• Does not occur immediately post op--affects 50% of patients within one year
• Avoid lifting over 5 pounds for 6-8 weeks after surgery (Wound Ostomy and Continence Nurses Society, 2014)�

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Betty White is a 53 year old patient with hx of ovarian CA who is admitted with ruptured diverticulitis. The surgery was done emergently. The surgeon performs a colon resection.

What type of ostomy is this?

Any skin problems that you can see?

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Let’s stop for a minute…

Nancy Nurse gives you report and tells you that she had to change the appliance twice yesterday for Mrs. White.

Why do you think it is leaking?

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Peristomal skin

• Peristomal skin should be intact and appear like skin elsewhere on the abdomen
• Only clean peristomal skin with water (Rolstad & Erwin-Toth, 2004;Dorman, 2009)

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Peristomal complications

Irritant dermatitis

• Skin is red and irritated from contact with output
• Can become denuded and weepy and can be painful
• Remeasure stoma and cut hole to correct size
• Crust with stoma powder and skin prep (Carmel, Colwell & Goldberg, 2016; Stelton & Holmsted, 2010;Stelton, Zulkowski & Ayello, 2015)

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Crusting Technique

https://www.youtube.com/watch?v=v83hWZDMpgE

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(Hooper, 2014)

Andrea Wohlenberg. Crust 1-7

Peristomal complications

Fungal/Candidiasis Infection

• Red itchy rash with satellite lesions
• Often seen in patients on antibiotics, who are immunosuppressed, diabetics or on steroids
• Washing peristomal skin with antibacterial soaps changes the pH of skin making more susceptible
• Topical antifungal powder crusted with skin prep (Carmel, Colwell & Goldberg, 2016; Stelton, Zulkowski & Ayello, 2015)

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Peristomal complications

Allergic Contact Dermatitis

• Red with pinpoint rash and blisters
• Mirrors the area in contact with the allergen
• Identify and remove allergen (Carmel, Colwell & Goldberg, 2016; Stelton & Holmsted, 2010)

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Stoma Malfunction

Passing stool/mucus via rectum

• Common especially if rectum still present (Stelton & Holmsted, 2010)

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Stoma malfunction

Ileostomy--diarrhea

• Large amount of output
• Monitor for dehydration (Stelton & Holmsted, 2010)
• Encourage patient to eat foods that help thicken stool (Dorman, 2009)
• Urgent if prolonged or patient is dehydrated(Stelton & Holmsted, 2010)

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Stoma Malfunction

Ileostomy--no output

• Food blockage more common due to small lumen
• Drink clear liquids
• Massage area around stoma
• Urgent if does not resolve in a couple of hours (Stelton & Holmsted, 2010)

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Stoma malfunction

Urostomy--no output

• May indicate severe dehydration or renal failure
• URGENT call MD (Stelton & Holmsted, 2010)

Urostomy--fever,chills, back ache, malaise

• s/s of urinary tract infection and can lead to sepsis
• URGENT call MD (Stelton & Holmsted, 2010)

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Urostomy management

Prevention of infection

• Drink enough fluids 2-2.5liters/day
• Use pouch with anti-reflux feature
• Empty the pouch when ¼-⅓ full
• Use nighttime drainage bag (Colwell, Goldberg, & Carmel, 2004)�

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Pouching Options

One piece pouches

• Barrier/base and pouch are all in one
• Ease of use for patients with limited hand strength/dexterity
• More flexible (Erwin-Toth, 2003)

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Pouching Options

Two piece pouches

• Pouches can be removed without removing barrier/base)
• Easier to use if poor vision
• Usually not as flexible as a one piece (Erwin-Toth, 2003)

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Pouching Options

Flat barrier/base

• Start with this type--one piece or two piece
• Soft flat pouching system works better on a round firm abdomen (Dorman, 2009; Potts & Hocevar, 2009)

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Pouching Options

Convex barrier/base

• Has an outward curve which presses down around the stoma to make the stoma stick out more and makes a better seal

Use with caution on new stoma less than one week post operatively because it can increase the chance of mucocutaneous separation (Wound Ostomy and Continence Nurses Society, 2007)

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Pouching Options

Convex barrier/base

• Indications for use
• Flush or retracted stoma
• Flaccid or soft abdomen
• Stoma is in skin folds
• Leakage with current system (Potts & Hocevar, 2009;Wound Ostomy and Continence Nurses Society, 2007)

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What are you seeing here?

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What should you do?

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What type of pouch should you use?

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Andrea Wohlenberg. Stoma 3

Let’s stop for a minute…

Accessories

Adhesive remover

• Assists with barrier/base removal and helps prevent mechanical skin damage (Barnwell, 2015)

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Accessories

Skin prep

• Skin barrier film to put protective layer on skin(Carmel, Colwell & Goldberg, 2016)

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Accessories

Stoma powder

• Contain hydrocolloids that absorb moisture
• Use to crust provide dry surface (Carmel, Colwell & Goldberg, 2016: Colwell, et al.,2011)

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Accessories

Stoma paste

• Adhesive hydrocolloid mixture
• Caulks the cut edge of the barrier/base to fill in uneven areas and seal
• Contains alcohol so can sting if skin is damaged
• Not recommended to use with urostomy because urine erodes the paste(Carmel, Colwell & Goldberg, 2016)�

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Accessories

Moldable ring

• Adhesive hydrocolloid ring that assists with leveling out area around stoma ()
• Makes a seal between barrier/base and skin (Carmel, Colwell & Goldberg, 2016; Neil, Inglese, & Townshend, 2016)

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Accessories

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Belt

• Attaches to the barrier/base or pouch to apply pressure to the pouching system to help with adherence (Carmel, Colwell & Goldberg, 2016)

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Pouching options

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(Dorman, 2009)

Any questions?

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Let’s take the post test and see how we do compared to before the presentation

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Please complete the evaluation form and return it

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References

Barnwell, A. (2015, September 24-October 7). Stoma accessories and quality of life. British Journal of Nursing, 24(17), S22. http://dx.doi.org/10.12968/bjon.2015.24.Sup17.S22

Barr, J. E. (2004, September). Assessment and management of stomal complications: a framework for clinical decision making. Ostomy Wound Management, 50(9), 50-52,54,56. Retrieved from http://www.o-wm.com/home

Burch, J. (2005, March 24-April 13). The pre- and postoperative nursing care for patients with a stoma. British Journal of Nursing, 14(6), 310-318. Retrieved from http://info.britishjournalofnursing.com/

Butler, D. L. (2009, September/October). Early Postoperative Complications Following Ostomy Surgery: A Review. Journal of Wound, Ostomy and Continence Nursing, 36(5), 513-519. http://dx.doi.org/10.1097/WON.0b013e3181b35eaa

Carmel, J. E., Colwell, J. C., & Goldberg, M. T. (Eds.). (2016). Wound, Ostomy and Continence Nurses Society Core Curriculum: Ostomy Management. Philadelphia, PA: Wolters Kluwer.

Colwell, J. C., Goldberg, M. T., & Carmel, J. E. (2004). Fecal and Urinary Diversions Management Principles. St. Louis, MO: Mosby.

Colwell, J. C., Ratliff, C. R., Baharestani, M. M., Bliss, D. Z., Gray, M., Kennedy-Evans, K. L., ... Black, J. M. (2011, September-October). MASD part 3: peristomal moisture- associated dermatitis and periwound moisture-associated dermatitis: a consensus. Journal of Wound, Ostomy and Continence Nursing, 38(5), 541-553. http://dx.doi.org/10.1097/WON.0b013e31822acd95

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Cross, H. H., Roe, C. A., & Wang, D. (2014, November/December). Staff Nurse Confidence in Their Skills and Knowledge and Barriers to Caring for Patients with Ostomies. Journal of Wound, Ostomy and Continence Nursing, 41(6), 560-565. http://dx.doi.org/10.1097/WON.0000000000000065

Dorman, C. (2009, July 01). Ostomy basics: A nurse's introduction to care, counseling, and equipment. Modern Medicine Now. Retrieved from http://www.modernmedicine.com/

Doughty, D. (2008, January/February). History of Ostomy Surgery. Journal of Wound, Ostomy and Continence Nursing, 35(1), 34-38. http://dx.doi.org/10.1097/01.WON.0000308617.94131.f8

Erwin-Toth, P. (2003, May-June). Ostomy pearls: a concise guide to stoma siting, pouching systems, patient education and more. Advances in Skin and Wound Care, 16(3), 146-152. Retrieved from http://journals.lww.com/aswcjournal/pages/default.aspx

Hooper, J. (2014, January 10). Crusting around an ostomy stoma [Video file]. Retrieved from https://www.youtube.com/watch?v=v83hWZDMpgE

Kwiatt, M., & Kawata, M. (2013, June). Avoidance and Management of Stomal Complications. Clinics in colon and rectal surgery, 26(2), 112-121. http://dx.doi.org/10.1055/s-0033-1348050

Leyk, M., Ksiazek, J., Habel, A., Dobosz, M., Kruk, A., & Terech, S. (2014, November/December). The Influence of Social Support From the Family on Health Related-Quality of Life in Persons with a Colostomy. Journal of Wound, Ostomy and Continence Nursing, 41(6), 581-588. http://dx.doi.org/10.1097/WON.0000000000000086

Lyon, C. C., & Smith, A. (Eds.). (2010). Abdominal Stomas and their Skin Disorders (2nd ed.). London: Informa Healthcare.

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Neil, N., Inglese, G., & Townshend, A. (2016, January-February). A Cost-Utility Model of Care for Peristomal Skin Complications. Journal of Wound, Ostomy and Continence Nursing, 43(1), 62-68. http://dx.doi.org/ 10.1097/WON.0000000000000194

Ostomy Skills: Emptying and changing the pouch [PDF]. (n.d.). Retrieved from https://www.facs.org/education/patient-education/skills-programs/ostomy-program/home-care-booklet

Persson, E., & Hellstrom, A. (2002, March). Experiences of Swedish Men and Women 6 to 12 Weeks after Ostomy Surgery. Journal of Wound, Ostomy and Continence Nursing, 29(2), 103-108. http://dx.doi.org/10.1067/mjw.2002.122053

Potts, C., & Hocevar, B. J. (2009, July/August). Serious Pouch Fitting Challenge in a Patient with an Ileal Conduit. Journal of Wound, Ostomy and Continence Nursing, 36(4), 444-446. http://dx.doi.org/10.1097/WON.0b013e3181ac060f

Rolstad, B. S., & Erwin-Toth, P. L. (2004, September). Peristomal skin complications: prevention and management. Ostomy Wound Management, 50(9), 68-77. Retrieved from http://www.o-wm.com/home

Shultz, J. M. (2002, October). Preparing the patient for colostomy care: a lesson well learned. Ostomy Wound Management, 48(10), 22-25. Retrieved from http://www.o-wm.com/home

Smith, D. M., Loewenstein, G., Rozin, P., Sherriff, R. L., & Ubel, P. A. (2007, August). Sensitivity to disgust, stigma, and adjustment to life with a colostomy. Journal of Research in Personality, 41(4), 787-803. Retrieved from https://www.elsevier.com/

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Stelton, S., & Homsted, J. (2010, July/September). An ostomy-related problem-solving guide for the non-ostomy therapist professional. World Council of Enterostomal Therapists, 30(3), 10-19. Retrieved from http://www.wcetn.org/journal

Stelton, S., Zulkowski, K., & Ayello, E. A. (2015, June). Practice Implications for Peristomal Skin Assessment and Care from the 2014 World Council of Enterostomal Therapists International Ostomy Guideline. Advances in Skin & Wound Care, 28(6), 275-284. http://dx.doi.org/10.1097/01.ASW.0000465374.42350.0f

Wound Ostomy and Continence Nurses Society. (2007). Convex Pouching Systems: A Best Practice Document for Clinicians. Mt. Laurel, NJ: Wound Ostomy and Continence Nurses Society.

Wound Ostomy and Continence Nurses Society. (2014). Stoma Complications: Best Practice for Clinicians. Retrieved from http://c.ymcdn.com/sites/www.wocn.org/resource/resmgr/Publications/Stoma_Complications_Best_Pra.pdf

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