STOMA CARE
DEFINITION
A stoma is an opening that is created to allow
stool or urine to pass out of the body.
Although more common in adults, it is not
unusual for a child to have ostomy surgery.
For some the stoma is carried out as a
temporary measure, to allow the gut a period
of rest and recovery, whilst for others it may
be permanent, having been carried out as a
life-saving measure
INDICATIONS
FOR
OSTOMY
Some of the most common conditions that might
necessitate a stoma are:
Imperforate anus: where there is no exit for the
bowel or its contents.
Hirschsprungs disease: where nerves called the
ganglion nerves are missing and waste matter
cannot easily pass.
Inflammatory bowel disease: this includes Crohns
Disease and Ulcerative
Colitis, both inflammatory diseases of the
intestines.
Neonatal necrotising enterocolitis: this occurs
when a portion of the bowel is dead and cannot
function and is most common in premature
babies who weight less than 3 pounds at birth. In
this case a stoma can mean life to a baby.
Spina bifida: where part of the spine fails to
develop properly and in more severe forms of the
disease, the spinal nerves that control the
muscles of the legs, bladder and bowels may be
affected and a stoma needed.
Stomach
Large Bowel
(colon)
Small Bowel
(ileum)
Rectum
Accident, injury and other causes: these include
cancer and also injuries to the bowel or bladder
caused by car accidents, etc
After surgery, your child will pass stool/ urine
through the stoma instead and will not be able to
control when this occurs. To help with this a pouch
is worn to collect the waste.
COMMON
APPEARANCE
OF
STOMA
Stomas will be a pinkish red in colour, similar to the inside
of your mouth, and will be soft and moist.
Do not be alarmed if your child’s stoma looks different
from other pictures you may have seen as the appearance
of the stoma will be unique.
It is also common for the stoma and the area around it to
be slightly swollen for around 6-8 weeks after surgery, after
which the swelling will subside.
Sometimes the stoma may bleed a little, for instance if
brushed by a towel or dressing. This is entirely normal as
stomas have a lot of blood vessels and the bleeding usually
stops very quickly.
Stomas have no nerve endings and therefore no
feeling so it will not hurt when touched.
Dependent on the type of stoma, it can be located
on different parts of the body.
Dependent on the type of stoma, the output will
be different.
The stoma may sit out above or be slightly below
the skin level.
The stoma may grow with your child, especially if it
is permanent. It is important, therefore to remeasure the stoma from time to time to ensure
that the pouch still fits correctly.
At times when your child is crying you may notice a
change in the colour of the stoma. However, the
normal colour will return when the crying stops.
TYPES
OF
STOMA
There are 3 types of stoma and the type of stoma your
child has will be determined by the reason for the
surgery.
Colostomy
This is the most common stoma type for a baby or child. A
colostomy is an opening made into the large intestine or colon.
The stool can then pass from the stoma out of your child’s body
which tends to be solid in consistency but can sometimes be
liquid.
Ileostomy
In an ileostomy the opening is made in the small
intestine – the ileum. An end or loop of the small
intestine is brought through the skin’s surface on your
child’s abdomen and the output then passes out
through the stoma. The ileostomy will resemble a
‘spout’ because the waste is more liquid. Due to the fact
that ileostomy output contains digestive enzymes, this
can be harmful to the skin and so requires extra care
when pouching.
Urostomy
A urostomy is an opening made to divert urine from the
bladder and also resembles a ‘spout’ as the output is urine.
SELECTING
YOUR
CHILD’S
APPLIANCES
Before leaving hospital with your child, your Stoma Care
Nurse will be able to answer any queries that you may
have. Be sure to ask them any questions that might be
concerning you and also ensure that you are prepared for
the pouch changing regime. You should have the
opportunity to help the nurse out with pouch changes
to build your own confidence.
•A hypo-allergenic skin protector that is kind and gentle on
young skin. This skin protector is also ultra-thin and moulds
to create a secure fit.
• A soft, skin-tone fabric that is cool and comfortable against
the skin. The Pelican Pouch range all have teddy bear
printed fabric with a split backing to allow easy viewing of
the stoma without removing the pouch and enables easier
pouch fitting.
• A waterproof filter system to allow controlled deodorized
airflow.
• Where the waste is fairly runny (e.g. with an ileostomy or
some colostomies) a drainable pouch should be used. Our
range of Pelican Pouches with their Clip less Closure System
ensures the pouch is very quick and easy to empty and
clean.
What types of products are used for colostomies?
Pouch: There are a variety of sizes and styles of colostomy
pouches. Pouches are lightweight and odor-proof. Pouches have
a special covering that prevents the pouch from sticking to the
body. Some pouches also have charcoal filters which release gas
slowly and help to decrease gas odor. The following is general
information about types of colostomy pouches:
Open-ended pouch: This type of pouch allows you to open
the bottom of the pouch to drain the output. The open end is
usually closed with a clamp. The open-ended pouch is usually
used by people with ascending or transverse colostomies. The
output from these colostomies is looser and is unpredictable
(does not drain at regular times).
Close-ended pouch: This type of pouch is removed
and thrown away when the pouch is filled. Closeended pouches are usually used by people with a
descending or sigmoid colostomy. The output from
these types of colostomies is firm and does not need
to be drained .
One-piece: A one-piece pouch contains the pouch
and adhesive skin barrier together as one unit. The
adhesive skin barrier is the part of the pouch system
that is placed around the stoma and attached to
skin. When the pouch is removed and replaced with
a new one, the new pouch must be reattached to
the skin.
Two-piece: The two-piece pouch has two parts: an
adhesive flange and pouch. The adhesive flange
stays in place while the pouch is removed and new
pouch is attached to the flange. The pouch does not
need to be reattached to the skin each time. The
two-piece system can be helpful for patients with
sensitive skin.
Pre-cut or cut-to-fit pouches: Some pouches have
pre-cut holes so you do not have to cut the opening
yourself. Other pouches can be cut to fit the size and
shape of your stoma. Cut-to-fit pouches are
especially useful right after your surgery because
your stoma decreases in size for about eight weeks.
Stoma covers and caps: Stoma caps or covers can be placed on the
stoma when the stoma is not active (draining). People with
descending or sigmoid colostomies who irrigate may use stoma
covers or caps. The cover or cap is attached to the skin in the same
way as a pouch.
Skin protection:
Film: A film can be placed on the skin to protect against
damage from the adhesive material. Films are helpful for
people with sensitive, dry, or oily skin.
Pectin-based paste or paste strips/rings: These products are
helpful for protecting skin against output that contains
digestive enzymes (proteins that break down foods). Ascending
or transverse colostomies can produce output that contains
digestive enzymes, which can irritate or damage the skin. The
paste is also used to create a flat pouch surface by filling in
small skin creases
HOW
TO
CHANGE
POUCH
The way in which you should change your colostomy pouch
depends on the type of pouch you use. Your caregiver will give you
specific instructions on how to change your colostomy pouch. The
following is general information about how to change your pouch:
Ask your caregiver about how often to change your colostomy
pouch. The amount of time that you should leave your pouch on
your abdomen depends on many things. The type of pouch you
wear affects the amount of time you can wear a pouch. The kind
and amount of stool you have also affects how long the pouch stays
on.
If you are wearing an open-ended pouch, empty the contents from
pouch into the toilet. Gently remove the pouch by pushing the skin
down and away from the adhesive skin barrier with one hand. With
the other hand, pull the pouch up and away from the stoma.
Clean the skin around the stoma with warm water. You may also use soap but do
not use soaps that have oil or perfumes. Pat your skin dry.
Use a pouch that has an opening that is one-eighth of an inch larger than the
stoma.
Use skin protection products if you have irritated skin around the stoma. The
skin can be treated with these products to protect your skin and create a dry
surface.
Center the pouch over the stoma and press it firmly into place on clean, dry skin.
It may be helpful to hold your hand over the newly applied pouch for 30
seconds. The warmth of your hand can help to mold the adhesive skin barrier
into place.
Place the old pouch in another plastic bag to be thrown away if the pouch is
disposable. If you use a reusable pouch, talk to your caregiver about how to
clean the reusable pouch.
HOW
TO
EMPTY
POUCH
Empty the pouch when it is one-third to one-half full. Do
not wait until the pouch is completely full because this
could put pressure on the seal, causing a leak. The pouch
may also detach, causing all of the pouch contents to
spill.
Place toilet paper into the toilet to reduce splash back
and noise.
Take the end of the pouch and hold it up. Remove the
clamp (if the pouch has a clamp system).
You may need to make a cuff at the end of the pouch to
keep it from getting soiled.
Drain the pouch by squeezing the pouch contents into
the toilet.
Clean the cuffed end of the pouch with toilet paper or a
moist paper towel. You may also rinse the pouch but it is
not necessary. Make sure and keep the end of the pouch
clean.
Undo the cuff at the end of the pouch. Replace the clamp
or close the end of the pouch according to your
caregiver's instructions.
IRRIGATION
People with descending or sigmoid colostomies may be able to irrigate
their colostomies on a regular basis. Irrigating the stoma means putting a
fluid into the stoma to empty the bowel. This may also be called an
enema. Irrigation allows a person to have timed bowel movements.
Irrigation can allow a person to be free from stool output for about 24 to
48 hours. Once stool output is regular, a stoma cap can be used between
irrigations instead of using a drainable pouch. The stoma cap will absorb
mucus and deodorize and vent gas.
Irrigation may be right for you if you had regular bowel movements before
the colostomy. You should also be physically able to perform the irrigation
procedure. It is also important to have a lifestyle that will allow regular
irrigation. For example, you should have a daily schedule in which you can
schedule enough time to regularly irrigate. You should also be free from
certain colostomy problems. People with problems such as a prolapse or a
hernia should not irrigate. Irrigation could make a prolapse worse or
create a hole in the bowel. Irrigation could also cause leakage of stools
between irrigations or make it hard to control bowel movements.
HOW
TO
IRRIGATE
COLOSTOMY
You will need a plastic irrigating container with a long tube and a cone to
introduce water into the colostomy. You will also need an irrigation
sleeve that will direct the output into the toilet. You will need
an adjustable belt to attach the irrigation sleeve and a tail closure for the
end of the sleeve.
Choose the same time each day when you will not be interrupted to
irrigate your colostomy.
Fill the irrigating container with about 16 to 50 ounces (500 to 1500 mL)
of lukewarm water. The water should not be cold or hot. The amount of
water each person needs to put in the irrigating container varies. Ask
your caregiver how much water you will need to irrigate. Hang the
irrigation container at a height in which the bottom of the container is
level with your shoulder. Sit up straight on the toilet or on a chair next to
the toilet.
Take the adjustable belt and attach it to the irrigation
sleeve. Place the belt around your waist and place the
sleeve over your stoma. Place the end of the irrigation
sleeve into the toilet bowel.
Release air bubbles from the tubing on the plastic
irrigating container by releasing the clamp. Allow a small
amount of water to be released into the sleeve. Clamp
the tubing again.
Moisten the end of the cone with water or lubricate it
with water-soluble lubricant.
Place the tip of the cone about three inches deep into the stoma.
Make sure there is a snug fit but do not place the cone too deeply
or forcefully into the stoma. Release the clamp on the tubing again
and allow the water to flow into the stoma. The water must go in
slowly and takes about five to ten minutes. Keep the cone in place
for another 10 seconds.
Remove the cone from the stoma. Allow the output to drain into
the irrigation sleeve for about 10 to 15 minutes. Dry the end of the
irrigation sleeve. Clip the bottom of the sleeve to the top with a
clasp or close the end of the sleeve with the tail closure. You may
move around for about 30 to 45 minutes until all the water and
stool has drained. Drain the output from the sleeve into the toilet.
Clean the area around the stoma with mild soap and water and pat
dry
COMPLICATIONS
Most stoma problems happen during the first year after surgery.
Stoma retraction: Retraction happens when the height of the
stoma goes down to the skin level or below the skin level.
Retraction may happen soon after surgery because the colon does
not become active soon enough. Retraction may also happen
because of weight gain. The pouching system must be changed to
match the change in stoma shape.
Peristomal hernia: Peristomal hernias occur when part of the
bowel (colon) bulges into the area around the stoma. Hernias are
most obvious during times when there is pressure on the
abdomen. For example, the hernia may be more obvious when
sitting, coughing, or straining. Hernias may make it difficult to
create a proper pouch seal or to irrigate. The hernia may be
managed with a hernia belt. Changes may also need to be made to
the pouching system to create a proper seal. Surgery may also be
done in some people.
Prolapse: A prolapse means the bowel becomes longer
and protrudes out of the stoma and above the abdomen
surface. The stomal prolapse may be caused by increased
abdominal pressure. Surgery may be done to fix the
prolapse in some people.
Stenosis: A stenosis is a narrowing or tightening of the
stoma at or below the skin level. The stenosis may be mild
or severe. A mild stenosis can cause noise as stool and gas
is passed. Severe stenosis can cause obstruction
(blockage) of stool. If the stoma is mild, a caregiver may
enlarge it by stretching it with his finger. If the stenosis is
severe, surgery is usually needed.