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Stoma and Wound Considerations: Nursing Management
Rehabilitation of the patient with a stoma or complicated wound is the responsibility of the entire health care team, and thus it is important that all members understand the principles and techniques of ostomy and wound management. As Dr. Rupert B. Turnbull, Jr., discovered in the 1950s, collaboration between the surgeon, the floor and clinic nurse, and the wound, ostomy, and continence nurse (previously known as the enterostomal therapy nurse) can facilitate this goal.
Preoperative Preparation
When an ostomy is a planned procedure, the opportunity exists for preoperative counseling and education that ideally involves the patient and his or her family, and stoma-site marking can be performed. However, every bowel surgery carries a risk of involving a stoma, even if it is extremely unlikely. This eventuality should be discussed preoperatively so that if it happens, the patient is not completely taken aback. In cases of an unexpected stoma, all the counseling and education takes place postoperatively.
Preoperative Counseling
Successful rehabilitation begins with the initial interaction with the patient. The patient and family must have a thorough understanding of the surgical procedure and likely changes to lifestyle it will cause. The alterations in anatomy and bowel and bladder function, the need for pouching, and the impact of a stoma on activities of daily living should be discussed.
Stoma Site Marking
Regardless of whether a stoma is to be temporary or permanent, stoma site marking is a key to optimizing the patient’s experience. A poorly sited and constructed stoma can be a nightmare for the patient, causing frequent leakage with skin erosion and pain, pouching difficulties, and social isolation. The best sites are usually located in the right or left lower quadrants, in the middle of rectus abdominus, away from any scars, creases, or dimples, and on the apex of the natural roll of the abdominal wall. The likely site should be checked with the patient supine, sitting, standing, and bending. The site should be visible to the patient when he or she is sitting. Some patients with pendulous abdomens or those who require constant use of a wheelchair may require a site in the upper quadrant. The procedure for selecting and marking the stoma site is provided in Box 91-1 .
BOX 91-1
Criterion Checklist for Stoma Site Marking
- 1.
Gather equipment
- 2.
Explain procedure to patient
- 3.
Wash hands
- 4.
Apply nonsterile gloves
- 5.
With the patient supine, locate the borders of the rectus abdominus muscle
- A.
Ask the patient to lift his or her head from the bed (i.e., perform a modified sit-up), cough, or laugh
- B.
Palpate the abdomen to identify the borders of the rectus muscle
- A.
- 6.
With the patient in the supine position, locate a possible stoma site in the following manner:
- A.
Place a stoma-marking disk on the abdomen within the anatomically appropriate quadrant for the type of stoma
- B.
Position a stoma-marking disk on an area of smooth skin surface within the quadrant, avoiding the umbilicus, bony prominences (e.g., the iliac crest, symphysis pubis), creases/folds, wrinkles, scars, the belt line, and areas of previous radiation treatment
- C.
Using a water-soluble pen, mark the possible stoma site with an “x” or circle in the center opening of the marking disk
- A.
- 7.
Use a marking disk as needed to assess the initial stoma site with the patient sitting, standing, and bending; relocate the site if necessary to avoid creases, wrinkles, and irregular contours that become apparent with change of patient’s position; mark the relocated site with a water-soluble pen
- 8.
With the patient sitting and standing, determine that the site is located on the summit (apex) of the infraumbilical fat mound
- 9.
Assess the patient’s ability to see and reach the stoma site by asking the patient to touch the stoma site while in the sitting and standing positions
- 10.
With the patient in the supine position, tattoo or indelibly mark the selected stoma site
- A.
Tattoo Method
- a.
Cleanse the site with alcohol and allow to dry
- b.
Drop a small amount of India ink on the site
- c.
Using a sterile 25-gauge needle, puncture the skin three times through a drop of ink
- d.
Spread the skin
- e.
Cleanse residual ink from the skin with dry gauze followed by an alcohol wipe
- f.
If necessary, circle the tattoo with indelible ink with a contrasting color
- g.
Apply a small adhesive bandage as needed
- a.
- B.
Indelible Marker Method
- a.
Using an indelible pen, mark the preferred stoma site with an “x” or circle
- b.
Cover the mark with a transparent film dressing
- a.
- A.
- 11.
Remove gloves
- 12.
Wipe the pen and marking disk with alcohol wipes
- 13.
Discard waste in the appropriate container
- 14.
Wash hands
- 15.
Document the procedure in the electronic medical record
Preoperative stoma site selection for the patient undergoing an ileal pouch–anal anastomosis needs to take into account the mesenteric tension created by the anastomosis, which often forces the segment of ileum used for the stoma to be relatively proximal, especially in obese persons. Stomas made under these conditions have high output that is difficult to control. It is essential that such ileostomies have a good spout to prevent undermining of the skin protection by the watery stool. It is a good idea to mark two sites, one in the upper and one in the lower abdomen, so that any eventuality is covered.
Stoma marking for patients undergoing a continent ileostomy may be lower on the abdomen, and adjacent scars and folds are less of an issue, because the stoma is flush and continent. The site must still be visible to a standing or sitting patient so that the drainage catheter can be inserted.
Postoperative Management
An ideal ileostomy is matured primarily and budded; a colostomy can be flush, but a small eversion of a centimeter makes pouching easier. A flush, retracted, or excessively elongated stoma can pose pouching difficulties. A clear pouch with a skin barrier should be applied in the operating room to permit the stoma to be adequately assessed postoperatively. The aperture in the adhesive skin barrier should be approximately 1/8-inch larger than the base of the stoma. The skin should be cleansed with nonlotion soap and dried prior to pouch application. The procedure for the application of a one-piece pouch is included in Table 91-1 . If a rod is present, a flat flexible pouching system should be fitted over, not under, the rod, and the pouch should be labeled “rod underneath” to prevent accidental dislodgement and mucosal trauma.
TABLE 91-1
Procedures for Changing Pouches
| How to Change a Disposable One-Piece, Cut-to-Fit Pouch with an Attached Skin Barrier | How to Change a Disposable Two-Piece Pouch with a Cut-to-Fit Skin Barrier Flange |
|---|---|
|
|
The pouch should be changed on the first postoperative day after conventional open surgery, with rod removal from day 3 to 5, depending on tension. For laparoscopic stomas, if the pouching system is adhering well, a pouch change is performed on postoperative day 2, when the rod is removed, depending on the tension. With each pouch change, the stoma, mucocutaneous junction, and peristomal skin are assessed. Postoperative stoma and peristomal skin complications and their management are described in Tables 91-2 and 91-3 . Stomas that are retracted or flush, as well as patients with a soft abdomen, may benefit from a convex pouching system. Principles of fitting are highlighted in Table 91-4 .
TABLE 91-2
Selected Stomal Complications
| Problem | Characteristics | Interventions |
|---|---|---|
| Mucocutaneous separation | Separation of the suture line at the junction of stomal mucosa and skin Erythema around the area of separation; may have drainage or pain at site Can be partial or circumferential; shallow or deep |
Assess depth of separation: if peritoneal contamination is a concern, resuture stoma to skin Shallow separation: use skin barrier powder to fill the defect, and pouch Deep separation: gentle packing with gauze may be necessary; cover with thin hydrocolloid or other appropriate dressing, and pouch If infection is a concern, use an antimicrobial dressing and antibiotics as needed If a large volume of fluid is draining from the separation, include the area in the pouch opening |
| Necrosis | Mucosal color dark red, maroon, purple, gray, brown, or black; stoma is dry, hard, or flaccid | Use a clear pouch in the postoperative period to allow for ongoing mucosal assessment Assess depth of necrosis If below the fascial level, perform a repeat operation with reconstruction of the stoma For superficial necrosis, provide conservative management with the tissue allowed to slough with debridement as needed |
| Parastomal abscess or fistula | Abscess adjacent to stoma Fistula may be present |
Administer systemic antibiotics Perform incision and drainage of the abscess site, which is best done with a mushroom-tipped catheter Perform contrast studies to define the extent of the fistula Perform surgical intervention as needed Modify the pouching system based on the location and extent of the fistula or abscess |
| Food bolus obstruction | Severe, crampy abdominal pain with nausea, vomiting Output may cease or become watery and odorous Stomal edema is common Patient relates recent history of ingesting high-fiber foods such as peanuts, popcorn, or string vegetables |
Conservative management: warm bath, peristomal massage, and liquids Supportive measures: intravenous fluid replacement, pain medications, and nasogastric tube Ileal lavage |
| Hernia | Hernia around stoma presents as a bulge that can interfere with pouch seal, causing mechanical or irritant contact dermatitis | Use of support belt Perform pouch modification to accommodate change in contour Consider discontinuing routine colostomy irrigation Surgical repair plus or minus relocation |
| Prolapse | Telescoping of the bowel through the stoma; length and diameter of mucosa increases with potential for laceration | Conservative: Manually reduce prolapse; apply binder with prolapse overbelt while the person is supine; reassess pouching system for proper aperture size Surgical management |
| Retraction | Stoma recedes below skin level, causing a variety of pouching and peristomal skin difficulties If a loop stoma recedes, it will not divert completely |
Assess for recurrent disease such as Crohn disease Refit pouching system often by increasing degree of convexity Perform surgical revision if pouching modification is not successful |
| Stenosis | Narrowing of the lumen of the stoma, which can lead to partial stomal obstruction | Preventive measures such as an appropriate pouching system, prompt treatment of pseudoverrucous lesions; avoid routine dilation of stoma Stool softeners and laxatives as needed Surgical revision |
| Trauma | Laceration or bruising of mucosa Lacerations are seen as yellow to white linear marks in the mucosa |
Identify and eliminate causative factor for the trauma, e.g., correct aperture, clothing alterations Use measures to control bleeding as needed |
TABLE 91-3
Selected Peristomal Skin Conditions
| Condition | Characteristics | Interventions |
|---|---|---|
| Allergic contact dermatitis | Allergic response caused by patient sensitivity to a particular product Area of response generally conforms to exposed area Skin appears erythematous, edematous, eroded, weepy, or bleeding Patient may report bleeding |
Remove offending product, avoid other irritants, and protect the skin Modify pouching system as needed, possible use of nonadherent system; patch test with other products as needed Use of corticosteroid agents as needed |
| Candidiasis or fungal rash | Generally diffuse erythematous papules Papules often coalese to form a plaque with characteristic advancing border with satellite lesions Proliferation of fungus is fostered by a warm, dark, moist environment Pruritus is common |
Eliminate moisture; use pouch covers; dry tapes with blow dryer on cool setting Assess pouching system for leakage and modify as needed Apply topical antifungal preparations May require systemic antifungal medications if rash recacitrant or severe |
| Caput medusa or peristomal varices | In patients with portal hypertension, the pressure at the portal systemic shunt in the mucocutaneous junction increases, creating venous engorgement seen as area of bluish purple discoloration of skin around the stoma; the area blanches when pressed, displaying irregular, small blood vessels Profuse bleeding can occur at the mucocutaneous junction If the stoma is relocated, varices eventually recur around the new stoma |
If bleeding occurs, direct pressure or use of hemostatic agents, e.g., silver nitrate, cautery, or suture ligation Careful pouch removal Avoid aggressive skin barriers Transjugular intrahepatic portosystemic shunt procedure may lower portal hypertension; liver transplant for severe disease |
| Chemical irritant dermatitis | Chemical destruction of the skin caused by improperly fitting pouch, leakage of pouch, or topical products Skin appears red and moist, with shallow erosions that are painful |
Dust denuded areas with skin barrier powder; if severe, may use astringent product The abdomen is assessed in the supine and sitting positions, with the pouching system refitted based on stoma size and abdominal contours Review product usage and techniques; revise as needed |
| Folliculitis | Inflammation of hair follicle due to traumatic removal of hair with resultant bacterial infection; lesions arise from hair follicle and are erythematous pinpoint pustules | Use proper pouch removal techniques with adhesive removers as needed Shave peristomal skin— electric razors preferred Apply topical antibacterial powders as needed |
| Mechanical trauma | External item or force causes damage to skin from pressure, laceration, friction, or shear; seen as pressure ulcer, red or denuded lesions with irregular borders; painful | Assess equipment and pouching technique Modify equipment and accessories to prevent reinjury Treat denuded tissue with skin barrier powder or other topical dressing as dictated by wound characteristics |
| Parastomal ulcer | Area of ulceration adjacent to stoma; varies in size, contour, level of pain Commonly seen in patients with Crohn disease. |
Unroof ulcer as needed Intralesional steroid injections or topical tacrolimus Topical management depends on size: options include skin barrier powder, nonadherent gauze, hydrogel, astringent solution, hydrocolloid wafer, foam, alginates, and hydrofiber Antimicrobial dressings are used as needed A nonadherent pouching system may be needed if ulcers are large Treatment of systemic disease |
| Pseudoverrucous lesions or hyperplasia | Overgrowth of tissue caused by overexposure to moisture Appears as raised, moist lesions with wartlike appearance Begin at base of stoma and extend outward; can be painful Difficulty with pouch adhesion |
Properly size aperture and convexity of pouching system; use extended-wear barriers with liquid effluent In severe cases, sharp debridement of skin or relocation of stoma may be required |
TABLE 91-4
Principles of Fitting: Pouches, Stomas, and Accessories
| Pouching Systems | |
|---|---|
| Types | Features and Varieties |
| One-piece drainable, closed-end, urostomy | Flexible, semiflexible, firm, with or without skin barrier attached Flat and with convexity ranging from shallow to very deep; precut and cut-to-fit types Clear or opaque pouches, adult or pediatric sizes Drainable, odor-proof pouches Urostomy odor-resistant pouches Built-in gas/deodorizing filters Belt hooks or optional gasket if use of belt is desired |
| Two-piece system | With or without adhesive tape collar Precut and cut-to-fit varieties Flat or built-in convexity or option of convex insert Adult and pediatric sizes Pouch removable without disturbing flange Clear and opaque pouches Variety of sizes and shapes of pouches, irrigation sleeves, and stoma caps |
| Abdomen/Stoma Considerations | ||
|---|---|---|
| Abdominal Type | Stoma Type | Appropriate Pouch |
| Firm | Flush Retracted Budded |
Flat/flexible |
| Soft | Flush Retracted Budded |
Semiflexible; shallow to medium convexity Flat or semiflexible; shallow convexity |
| Very soft | Flush Retracted Budded |
Firm; deep to very deep convexity ∗ Firm; deep convexity ∗ |
| Accessory Products | |
|---|---|
| Product | Use |
| Skin barrier paste | Enhances seal by filling the space between the stomal and pouch barrier edge To apply paste, use one of the following methods (but not both): Put the paste around the edges of the skin barrier opening, and let dry for at least 1 minute before applying pouching system to the skin Put the paste on the skin around the stoma and let dry for at least 1 min before applying the pouching system |
| Skin barrier powder | Provides an absorbent, protective layer for denuded or moist skin When using barrier powder, be sure to dust off the excess so that the pouch will stick securely to the skin |
| Sealant | Provides protective film surface to help prevent tearing of the skin when the adhesive pouch is removed; the sealant is placed under the tape collar of the pouch |
| Skin barrier | Protects the skin around the stoma from bowel drainage and creates a level pouching surface; barriers are also used to treat peristomal skin loss due to injury; barriers are available in regular and extended-wear formulations and come as wafers and washers (also called rings); skin barrier washers may be flat or convex |
| Pouch deodorant | Assists in controlling odor; when using pouch deodorant, it is best to place it in the lower half of an empty pouch; oral, aerosol, and charcoal filter products are used to assist with odor management |
| Belt | Provides support to the pouch at the 9 o’clock and 3 o’clock positions, which may optimize wear time; they are available in several adult and pediatric sizes; some belt brands can be used with any pouch, and other brands must be used with the pouch system of the same manufacturer |
| Binder | Helps support the abdomen and hold the pouch in place; they come in widths from 3 to 9 inches and can be ordered with a prolapse overbelt; binders can be custom ordered to accommodate stoma size and location, pouch size, and an individual’s particular abdominal variation, such as might occur with a hernia |
| Pouch cover | Controls moisture between the pouch and skin; they help make the pouch less noticeable, which can enhance body image; they are available in several adult and pediatric sizes to fit various pouches |
| Bedside drainage system for urinary stomas | Helps reduce or eliminate trips to the bathroom to empty the pouch during the night; these systems use plastic bags or bottles and have attached drainage tubing; an adapter is required to attach the urinary pouch to the drainage tubing; can be secured to the bed frame or placed in a plastic wastebasket on the floor |
| Underwear and swimwear | Support the pouch while making it less noticeable, which can enhance body image; they are available in several sizes and styles |
| Stoma guide strips | Assist patient in centering the pouch; guide strips are inserted into the pouch opening; because they are made of rice paper, guide strips dissolve when they come in contact with moisture |
| Tapes | Secure and support the pouching system; they are available from a variety of manufacturers in many sizes, styles, shapes, and types; waterproof tapes are available for patients who participate in water sports or activities |
| Solvents | Help remove the pouch and adhesive that is left on the skin between pouch changes; most solvents are petroleum-based and are available in liquid and “wipe” forms; after using solvents, be sure to wash and rinse the skin thoroughly to prevent chemical irritation |
∗ Inappropriate use of firm convexity can result in peristomal skin necrosis.
The need to minimize length of hospital stay provides the impetus to begin patient and family education as soon as possible. Learner readiness, considered essential for effective patient education, is not always realistic. All patients should be able to empty their bag and close it prior to discharge. If the patient is unable to independently change the pouch, a family member or friend is taught or home care or posthospital care stays are arranged. Although generally the pouch change procedure is not complex, learning can be complicated by the effects of pain medications, anesthesia, and the emotional adjustment to the stoma.
Special Considerations
Continent ileostomy
To maintain the patency of the catheter, gentle irrigation with 30 mL of normal saline solution every 2 hours is advisable in the immediate postoperative period. This interval can be modified based on individual patient needs. Patients with continent diversions will be discharged wearing a catheter and leg bag with a bedside drainage bag available at night. One convenient way to stabilize the catheter is to use a stoma plate and baby bottle nipple.
Intubation instructions are provided approximately 3 to 4 weeks after surgery in the ambulatory care setting. Patients are asked to perform and repeat intubation; they are given written instructions to reinforce the information regarding technique and frequency of intubation. The frequency of intubation is generally every 2 hours the first week, and the interval is increased an hour per week up to every 4 to 5 hours. Patients may elect to maintain constant drainage at night or set an alarm to awaken them. Patients with stomas, but especially those with continent diversions, should be urged to wear a medical identification bracelet or necklace to alert emergency care personnel to their medical status.
Detailed written information regarding pouch and wound care procedures, frequency of change, specific ordering information for supplies—including product names and stock numbers—and sources of supplies should be provided. Dietary guidelines and other information relating to activities of daily living are also included ( Box 91-2 ). Patients are generally sent home with minimal supplies, and thus establishing a source of supply soon after discharge is imperative. A listing of patient resources should be made available.
BOX 91-2
Frequently Asked Questions About Ostomy Care
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