Stoma Complications:
Best Practice for
Clinicians
Stoma Complications:
Best Practice for Clinicians
The Wound, Ostomy and Continence Nurses Society™ suggests the following format for bibliographic citations:
Wound, Ostomy and Continence Nurses Society. (2014). Stoma Complications: Best Practice for Clinicians. Mt. Laurel: NJ. Author.
Copyright© 2014 by the Wound, Ostomy and Continence Nurses Society™ (WOCN®). Date of Publication: 11/26/2014. No part of this
publication may be reproduced, photocopied, or republished in any form, in whole or in part, without written permission of the WOCN Society.
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2
Acknowledgments
Stoma Complications: Best Practice for Clinicians
This document was developed and completed by the WOCN Society’s Clinical Practice Ostomy Committee in August 2013.
Shirley Sheppard, Chair, MSN, CWON
Certified Wound Ostomy Nurse
University of Illinois Hospital and Health Sciences System
Chicago, IL
Jacqueline Perkins, MSN, ARNP, CWOCN, FNP
Wound Ostomy Nurse Practitioner
VA Central Iowa Health Care
Des Moines, IA
Carole A. Bauer, MSN, CWOCN, OCN
Advanced Nursing Practice
Karmanos Cancer Center
Detroit, MI
Anita Prinz, MSN, CWOCN, CFCN
Consulting
Holistic Ostomy and Wound Care
Boynton Beach, FL
Nina Blanton, CWOCN
Clinical Nurse Specialist
Palmetto Health Baptist
Columbia, SC
Michelle Rice, BSN, CWOCN
Ostomy Clinical Nurse Specialist
Duke University Hospital
Durham, NC
Joanne Burgess, BSN, CWOCN
Wound Ostomy Continence Nurse
WakeMed Health and Hospitals
Cary, NC
Christine Sterneckert, BSN, CWOCN
Consulting and Patient Care
Primary Children’s Medical Center
Salt Lake City, UT
Mary Mahoney, MSN, CWON
Certified Wound Ostomy Nurse
UnityPoint at Home
Urbandale, IA
Carla VanDyke, CWOCN
Clinical Nurse Specialist
Presbyterian Healthcare Services
Albuquerque, NM
Janet Mantel, MA, RNC, CWOCN
Certified Wound Ostomy Continence Nurse
Englewood Hospital and Medical Center
Englewood, NJ
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Introduction and Purpose
Ideally, a stoma should appear red or pink, moist, and slightly elevated from the surrounding skin. There may be underlying conditions that predispose certain
individuals to stomal complications. The seven most common stomal complications described in the literature are hernia, laceration, mucocutaneous separation,
necrosis, prolapse, retraction, and stenosis. This document was originally developed by the WOCN® Society’s Clinical Practice Ostomy Committee as a best
practice guide for clinicians who care for patients with ostomies (Wound, Ostomy and Continence Nurses Society [WOCN], 2005).
The purpose of this updated document is to facilitate the identification, assessment and management of common stomal complications. This document does
not include common peristomal skin conditions related to pouching problems. For each of the seven common complications, this best practice guide provides an
overview with a description and information about assessment and nursing interventions. The following information is provided for each complication: definition,
contributing factors/risks, potential complications, identifying characteristics, assessment parameters; and nursing interventions for prevention, management,
patient/caregiver education, and indications for referral to a primary healthcare provider. Also, recommendations for further research to expand the evidence-base
about stomal complications and their management are provided. Please see the appendix (Figures 1-7) for images of the seven stomal complications (WOCN,
2007a).
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PERISTOMAL HERNIA
Assessment
Definition
Identifying characteristics
• A peristomal hernia is a bulge under the peristomal skin • A bulge is noticeable around the stoma.
o The bulge can vary in size and it may be partial or
indicating that one or more loops of bowel have passed
circumferential.
through the dissected area of fascia and muscle, which
was needed to externalize the stoma; and the bowel is
• The bulge may reduce in size when the patient lies
now protruding into the subcutaneous tissue around the
down and increase in size when the patient stands, sits,
stoma (Thompson, 2008; WOCN, 2010, 2011).
or exerts him/herself.
o It affects up to 50% of patients within one year
• The stoma may also change in size or shape.
following creation of the stoma (WOCN, 2011).
• A hernia is often asymptomatic, or it can be
o It may be associated with a prolapsed stoma (Husain
symptomatic with pain, bulging, and poor fit of the
& Cataldo, 2008).
pouch (Bafford & Irani, 2013).
o Recurrence is common (Husain & Cataldo, 2008):
• Subclinical hernia: If the patient's history suggests a
 50-100% after local fascial repair.
hernia but the physical exam does not indicate a hernia
 4-44% after local laparoscopic fascial repair with
is present, then further testing may be indicated. A cat
mesh.
scan with oral contrast or an upper GI x-ray such as a
 68% after stoma relocation/translocation.
small bowel series or retrograde contrast study to
visualize the loops of bowel may help determine if a
hernia is present.
Description
Nursing Intervention
Prevention
• Marking the stomal site within the rectus muscle may
reduce the risk of a hernia developing (WOCN, 2011).
• Patients should:
o Lose excess weight prior to surgery (WOCN, 2011).
o Attain/maintain their waistline at less than 39.4
inches or 100 cm (De Raet, Delvaux, Haentjens, &
Van Nieuwenhove, 2008).
o Avoid lifting over 5 pounds for 6 to 8 weeks after
surgery.
o Stop smoking (Arumugam et al., 2003).
o Use abdominal support belts and garments when
doing heavy lifting or heavy work (WOCN, 2011).
o Support the abdominal area with a pillow or hands
when coughing or sneezing during the post-operative
period.
o Abstain from active abdominal exercises or lifting
heavy objects for at least 3 months following surgery
(WOCN, 2011).
o Maintain adequate postoperative nutrition (WOCN,
2011).
Contributing factors/risks
Assessment parameters
Management
• An aperture/opening through the abdominal muscle that • Assess for the following symptoms or problems:
• Modify the pouching system if needed: strategies to
o Abdominal pain.
is too large (WOCN, 2011; 2010).
consider include:
o A one-piece flexible system.
o Bowel obstruction.
• Obesity (Husain & Cataldo, 2008; WOCN, 2010,
o A two-piece system with a floating flange.
o Change in bowel habits.
2011).
o A two-piece flexible or flangeless system.
o
Difficulty
with
the
colostomy
irrigation
that
was
not
• Older age (Husain & Cataldo, 2008; WOCN, 2010,
o
Cautious use of tape to avoid shear.
present
prior
to
the
hernia.
2011).
o Cautious use of convexity to avoid pressure.
o Signs of ischemic bowel.
• Weakness of the abdominal musculature (WOCN,
o Adjusting the size and shape of the opening in the
• Monitor the skin for pressure areas from the pouching
2010, 20101).
skin barrier/wafer as needed.
system.
• Location of the stoma outside the rectus muscle
•
If
condition allows, measure the patient for a hernia
• Ask the patient if the wear time of the pouching system
(Husain & Cataldo, 2008; Thompson, 2008; WOCN,
support belt per manufacturer’s instructions, and apply
has
changed.
2010, 2011).
the belt with the patient in a supine/flat position.
• Observe for leakage and peristomal skin irritation.
• Waist circumference greater than 39.4 inches or 100
•
Use caution when irrigating a colostomy in a patient
• Remove the ostomy pouch and observe for a bulge
centimeters (De Raet et al., 2008).
who has a parastomal hernia, and use only a conearound the stoma when the patient performs the
• Wound infection (WOCN, 2010).
tipped irrigator to reduce any risk of perforation (Grant
Valsalva maneuver while standing and in a supine
• Excessive coughing and vomiting after surgery that
et al., 2012; Varma, 2009; Williams, 2011).
position (WOCN, 2011).
causes increased abdominal pressure (Bafford & Irani,
o Some experts consider a parastomal hernia as a
o While the patient performs the Valsalva maneuver,
2013; WOCN, 2011).
contraindication to colostomy irrigation (Carlsson et
gently perform a digital examination of the stoma to
• Stomal construction such as a double-barrel stoma or
al., 2010; Hatton & Brierley, 2011; Perston, 2010).
identify the fascial defect and bowel loop (WOCN,
loop colostomy (WOCN, 2011).
2011).
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Description
• Laparascopic technique for colorectal surgery where
the stoma is brought out through the same incision used
to remove the resected specimen (Randall, Lord,
Fulham, & Soin, 2012).
• Intra-abdominal tumor growth (WOCN, 2010, 2011).
• Pregnancy, if accompanied by excessive vomiting
(WOCN, 2010, 2011).
• Smoking tobacco (WOCN, 2010).
• Steroid use (Husain & Cataldo, 2008; WOCN, 2010,
2011).
• Emergency stoma placement or prior stoma placement
(WOCN, 2011).
Potential complications
• Stomal and peristomal changes that may cause leakage
of the pouching system and peristomal skin irritation.
• Mucosal stretching/spreading (WOCN, 2011).
• Incarceration, strangulation, perforation and complete
obstruction, which are the most dangerous
complications of a hernia and require emergency
surgery (Bafford & Irani, 2013; De Raet et al., 2008;
Heo et al., 2011; WOCN, 2011).
PERISTOMAL HERNIA
Assessment
Nursing Intervention
Patient/caregiving education
• Teach the patient to:
o Perform skin care and pouching procedures.
o Apply the support belt while lying down in a
reclining, flat position.
o Wear the support belt while up and ambulatory, and
remove it while in bed.
o Measure the stoma periodically and adjust the size of
the opening in the skin barrier/wafer as needed.
o Use only a cone-tipped irrigator for colostomy
irrigations.
 If patients have trouble instilling water during
colostomy irrigations or poor returns, they should
stop the irrigations.
 If the colostomy irrigation is stopped, the patient
may need a mild laxative and stool softeners or
dietary modifications to promote bowel regularity.
 Reassure the patient that the stoma should
continue to function without difficulty.
o Call their healthcare provider or ostomy nurse, or
seek emergency care if signs and symptoms of
blockage, obstruction, incarceration or strangulation
occur, such as (WOCN, 2011):
 Decreased output.
 Pain.
 Abdominal cramping.
 Distension around the stoma.
 Nausea and emesis (Kann, 2008).
 Dusky, black or necrotic color of the stoma (Shabbir
& Britton, 2010).
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Description
PERISTOMAL HERNIA
Assessment
Nursing Intervention
• If they are medically able, encourage patients to
exercise regularly to maintain abdominal muscle tone
and strength.
Refer to the primary healthcare provider
• Persistent peristomal skin irritation.
• Recurrent pouching difficulties.
• Signs and symptoms of incarceration and reduced blood
flow to the stoma (e.g., stoma turns gray, dark or
black), which indicates that the patient needs immediate
medical/surgical attention (WOCN, 2011).
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Description
Definition
• A stomal laceration is a cut or tear that most often
develops as a result of the pouching technique (e.g.,
stoma rubbing against part of the pouching system)
(Ratliff, Scarano, Donovan, & Colwell, 2005).
• Lacerations may also develop in conjunction with
trauma (e.g., car accident, shaving with a razor).
Contributing factors/risks
• Misalignment of the pouching system.
• A peristomal hernia.
• Stomal prolapse.
LACERATION
Assessment
Identifying characteristics
• The stoma’s mucosa presents with a yellow to white
linear discoloration.
• There is usually no pain associated with a laceration,
and bleeding may or may not be present.
• Lacerations usually heal when the causative factor is
removed.
Assessment parameters
• Assess the patient’s technique for applying the
pouching system.
o Examine the stoma while the pouching system is in
place to check for proper fit and alignment of the
skin barrier/wafer.
o Assess if belts or clothing are causing an improper
fit.
o Remove the skin barrier/wafer and assess for proper
fit.
• Rule out other stomal complications, such as Crohn’s
ulcer, malignant lesion, or diverticulosis.
Nursing Intervention
Prevention
• Cautiously clip or shave hair in the direction away from
the stoma to avoid cutting the stoma.
• Consider using a rigid, protective, dome cover over the
stoma during activities that have a potential for forceful
injuries, such as contact sports or physical labor.
Management
• Eliminate the factor(s) that caused the laceration.
• Resize the pouching system or the skin barrier/wafer so
that the stoma is not in contact with the flange or other
firm edges.
• Adjust tight clothing that may be impinging on the
stoma.
• Use hemostatic measures as needed to control bleeding
(e.g., silver nitrate, which may require an order from the
primary health care provider).
Patient/caregiver education
• Encourage the patient to follow preventive measures.
• Teach the patient:
o That blood in the pouch may be a sign of a laceration.
o To apply direct pressure to stop excess bleeding.
o Seek urgent medical assistance if bleeding does not
stop.
o Skin care and pouching procedures.
Refer to the primary healthcare provider
• Lacerations that do not heal.
• Uncontrolled or repeated bleeding.
• Severed stoma.
Potential complications
• Excessive bleeding.
• Compromised functioning of stoma which could require
emergent surgery.
• Severed stoma.
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MUCOCUTANEOUS SEPARATION
Description
Assessment
Definition
Identifying characteristics
• A mucocutaneous separation occurs when a stoma
• With a mucocutaneous separation, there is an
completely or partially separates/detaches from the skin
observable separation between the stoma and skin.
(Butler, 2009).
• The separation may be preceded by erythema, a darker
o It can be superficial or deep.
discoloration, or induration at the mucocutaneous
junction with absence of a ridge adjacent to the
mucosal-dermal junction.
Contributing factors/risks
Assessment parameters
• Conditions that compromise wound healing (Boyd• Describe the location/extent of the separation.
o The location of a separation is often described by
Carson, Thompson, & Boyd, 2004; Butler, 2009):
o Abdominal radiation.
referring to the stoma as the face of a clock (e.g.,
o Corticosteroid use.
mucocutaneous separation present from the 1 o’clock
o Diabetes.
to 3 o’clock position).
o Infection.
o Identify the depth of the separation in centimeters.
o Malnutrition (Butler, 2009).
 Gently measure the depth with a cotton-tipped
o Smoking (Franz et al., 2008).
applicator.
o Irritable bowel disease (Boyd-Carson et al., 2004).
 Do not force the cotton-tipped applicator into the
o Chemotherapy (Boyd-Carson et al., 2004).
defect.
o Fecal contamination at the suture line (Boyd-Carson
 If you are unfamiliar with this procedure, refer the
et al., 2004).
patient to a surgeon for further evaluation.
• Additional contributing factors/risks include:
• Identify if slough is present (Butler, 2009).
o An abdominal wall opening that is larger than the
• Assess if pain is present, which could indicate an
bowel.
underlying disease process, and may help determine
o Excessive tension on the suture line.
the extent of the separation.
o Stomal necrosis.
• Assess for a fistula if fecal material is in the separation
o Convexity, which may cause deeper tissue destruction
(Butler, 2009).
and impaired healing at the stoma/skin junction
• Assess the amount of drainage from the site, which
(WOCN, 2007b).
varies and might require more frequent pouch changes.
Potential complications
• Infection (Boyd-Carson et al., 2004; Butler, 2009).
• Peritonitis (Bafford & Irani, 2013).
• Stomal stenosis (Butler, 2009).
• Stomal retraction (Bafford & Irani, 2013).
Nursing Intervention
Prevention
• If possible, avoid early use of convexity (Rolstad &
Beaves, 2006).
• Seek a preoperative nutritional consult, as needed
(Fulham, 2008).
• Encourage pre-op and post-op smoking cessation
(Franz et al., 2008).
Management
• Flush the separated area with normal saline, tap water,
or a noncytotoxic wound cleanser.
• Fill the separation with a product to absorb drainage
and provide an environment for healing.
o Product selection may vary according to the depth
and amount of drainage (e.g., skin barrier paste, skin
barrier powder, calcium alginates, hydrofiber).
o After the defect is filled, apply the pouching system
over the separation, exposing only the stoma.
• Consider using a two-piece system with an easy-to
remove pouch (e.g., flangeless or floating flange) to
facilitate patient comfort during pouch removal and
reapplication.
• Change the pouching system more frequently if needed
to provide wound care to the separation:
o If wound care is needed daily or more often, consider
using a pouching system that allows access to the
separation, so the system does not have to be changed
with each treatment (e.g., two-piece system or wound
drainage collector).
Patient/caregiver education
• Teach the patient care of the mucocutaneous separation
and pouching procedures.
Refer to the primary healthcare provider
• Any separation that is suspected to extend below the
level of the fascia, which warrants referral to a surgeon.
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NECROSIS
Description
Definition
• Necrosis is tissue death that occurs when blood flow to
or from a stoma is impaired or interrupted.
Contributing factors/risks
• Edema of the bowel wall.
• Embolism/arterial compromise (Kann, 2008).
• Extensive stripping of/or tension on the mesentery.
• Hypotension/hypovolemia.
• Obesity.
• Sutures that are placed too close together or are too
tight.
• Constriction from a skin barrier/wafer opening that is
too small (Butler, 2009).
• Abdominal edema or distension (Butler, 2009).
Assessment
Identifying characteristics
• With necrosis, the stoma may be dark red, purplish,
dusky blue (cyanotic tint), gray, brown, or black.
• The mucosa may be soft and flaccid (Butler, 2009), or
it might be hard and dry.
• Necrosis is most likely to occur within the first 5
postoperative days.
• Necrosis often occurs within 24 hours of the surgery
(Butler, 2009; Colwell, Goldberg, & Carmel, 2004).
• The necrosis can involve the entire stoma or affect
only scattered areas, and it may be superficial or deep.
Assessment parameters
• Assess the color of the stoma and mucosal appearance
every 8 hours for the first 72 hours after surgery.
Notify surgeon if color is not red/pink.
• Monitor the stoma for progression of the necrosis and
for sloughing of the tissue.
o The necrotic tissue may cause an offensive odor.
• Consider assessing the level of necrosis/viability of the
stoma by gently inserting a clear, well-lubricated glass
tube into the stoma and visualizing the lumen of the
stoma using a penlight (Butler, 2009; Colwell et al.,
2004; Kann, 2008).
o When the light is shined into the tube, viable mucosa
appears red and healthy (Kann, 2008).
• Assess if the suture line is intact during changes of the
pouching system.
• Rule out melanosis coli, a condition in which the stoma
is brownish black due to excessive use of an
anthraquinone laxative such as cascara (McQuaid,
2012).
Potential complications
• Mucocutaneous separation.
• Peritonitis.
• Stomal retraction.
• Stomal stenosis.
Nursing Intervention
Prevention
• Monitor for increased edema and enlarge the stomal
opening of the pouching system, as needed, to prevent
constriction of the stoma.
• Assess for and recommend measures to manage
abdominal distension as needed (e.g., nasogastric tube).
• Assess for and recommend measures to manage
hypovolemia and hypotension (Butler, 2009).
Management
• Use a transparent pouch to visualize the stoma.
• Use a two-piece pouching system, so the pouch can be
removed as needed for close inspection of the stoma.
• Size the opening of the pouching system to prevent
constriction of the stoma.
• Resize the pouching system as nonviable tissue sloughs
and the stomal opening contracts.
• Monitor for stenosis.
Patient/caregiver education
• Prepare the patient for anticipated changes in the stoma
(e.g., color changes, tissue sloughing).
• Encourage the patient to observe the appearance of the
stoma on a daily basis, and to use a transparent pouch.
Refer to the primary healthcare provider
• Necrosis that extends beyond the level of the fascia,
which requires surgical intervention.
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PROLAPSE
Description
Assessment
Definition
Identifying characteristics
• A prolapse occurs when a full thickness length of bowel • The prolapsed bowel varies in length (e.g., 5-13
protrudes through an ostomy (Bafford & Irani, 2013;
inches), becomes edematous from the dependent
Butler, 2009).
position, is prone to bleed, and is at risk of trauma
(Butler,
2009).
• Loop colostomies prolapse more often than end
• The patient may not experience any pain or obstruction
colostomies (Bafford & Irani, 2013).
o Prolapse occurs in 2-22% of loop ostomies (Maeda et
with the prolapse (Husain & Cataldo, 2008).
al., 2003).
o Prolapses of transverse loop colostomies are the most
common, but prolapses can be seen with any stoma
(Husain & Cataldo, 2008).
• Classification of prolapsed stomas (Bafford & Irani,
2013):
o Fixed: Permanent eversion of an excessive length of
bowel.
o Sliding: Intermittent protrusion of bowel through the
stomal orifice, usually because of an increase in intraabdominal pressure, such as during the Valsalva
maneuver.
Contributing factors/risks
Assessment parameters
• An abdominal wall opening that is larger than the
• Assess:
o Presence of pain: A prolapse is usually painless
bowel.
(Husain & Cataldo, 2008).
• Inadequate fixation of the bowel to the abdominal wall.
o The stomal mucosa for trauma and laceration (Black,
• Increased abdominal pressure associated with tumors,
2009).
coughing, or an infant’s crying. Infants are at risk due to
o
The fit of the pouching system.
abdominal pressure while crying.
o The peristomal skin.
• Lack of fascial support such as with infants, adults after
o The viability of the stoma: Compromised circulation
multiple abdominal surgeries, or patients of advanced
may manifest as a dusky, purple, dark black, or very
age (Bafford & Irani, 2013).
pale stoma.
• Obesity.
o Presence of a peristomal hernia, which might be
• Pregnancy.
associated with a prolapsed colostomy.
• Weak abdominal muscle tone.
o Signs/symptoms of obstruction, incarceration, or
strangulation, which are absolute indications for
• Emergency surgery, which might result in:
surgical intervention/repair.
o A stoma that is not created through the rectus muscle.
o A large opening in the abdominal wall to
accommodate an intestine that is edematous at the
time of surgery (Husain & Cataldo, 2008).
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Nursing Intervention
Prevention
• If circumstances permit, for obese patients encourage
weight loss prior to surgery and long-term weight
management after surgery.
• Encourage patients who are medically able to exercise
regularly to maintain abdominal muscle tone and
strength.
Management
• With the patient in a reclining position, attempt to
manually reduce the prolapse by applying gentle
continuous pressure to the distal portion of the stoma.
• Manual reduction of an edematous, prolapsed stoma
may be enhanced by temporarily decreasing the edema
with an application of cold compresses or sugar to the
prolapse for 10-15 minutes (Butler, 2009; Husain &
Cataldo, 2008).
• Apply a support binder or an ostomy/hernia support belt
with a prolapse overbelt.
o The belt must be applied while the prolapse is
reduced, which is best accomplished with the patient
in a reclining, flat position (Butler, 2009).
• Revise the pouching system:
o Increase the size of the opening in the skin
barrier/wafer.
 Cut radial slits or darts in the skin barrier/wafer to
accommodate changes in the size of the stoma.
o Use a larger/longer pouch to accommodate the size
and length of the prolapse (Husain & Cataldo, 2008).
• Encourage a back-lying position for sleeping.
PROLAPSE
Description
Assessment
Potential complications:
• Poor fit of the pouching system (Bafford & Irani, 2013).
• Mucosal irritation or ulceration (Husain & Cataldo,
2008).
• Obstruction, incarceration, and strangulation (Bafford &
Irani, 2013; Husain & Cataldo, 2008).
Nursing Intervention
Patient/caregiver education
• Reassure the patient that the stoma should continue to
function without difficulty.
• Provide counseling regarding body image, as needed.
• Teach the patient:
o Skin care and pouching procedures.
o To monitor the stoma for changes in color, irritation,
laceration or bleeding.
o To notify their physician for changes in color of the
stoma or increased abdominal pain.
o To call their healthcare provider or ostomy nurse, or
seek emergency care if signs and symptoms of
blockage, obstruction, incarceration or strangulation
occur such as:
 Decreased or no output.
 Pain, abdominal cramping.
 Distension around the stoma.
 Nausea.
Refer to the primary healthcare provider
• Ischemia, obstruction or inability to reduce the stoma,
which warrants a surgical evaluation or intervention
(Butler, 2009).
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12
RETRACTION
Assessment
Definition
Identifying characteristics
• A retraction occurs when a stoma is drawn or pulled below • With a retraction, all or part of the stoma is
the skin level (Shabbir & Britton, 2010).
located below the skin level or the surrounding
skin pulls inward due to tension.
• A retraction may involve an entire stoma, or it may be
limited to the mucocutaneous junction.
• Depth of the retraction may increase when the
patient is in a sitting or supine position, and the
• Retractions are more common in patients with ileostomies or
stoma may not be visible when the patient sits
with Crohn’s disease, possibly due to the short and stiff
upright (Butler, 2009).
mesentery that has been thickened by edema.
• The presence or severity of a retraction can also
be affected by peristalsis (Butler, 2009).
Contributing factors/risks
Assessment parameters
• An abdominal wall opening that is larger than the bowel
• Observe for excessive pressure from use of
(Butler, 2009); infection; a mucocutaneous separation
convexity or a belt (Butler, 2009).
(Black, 2009; Butler, 2009); a necrotic stoma (Black, 2009). • Assess for leakage and peristomal skin irritation
due to feces or urine undermining the pouching
• Premature removal of the supporting device from a loop
stoma (Butler, 2009); a stoma located in a skin fold.
system:
o Fecal—severe skin erosion/ulceration.
• Malnourishment, obesity, steroid use, or immunosuppression
o Urine—encrustation, ulceration, and stenosis.
(Bafford & Irani, 2013; Kann, 2008).
• After removing the pouching system, observe the
• Tension on the stoma due to:
stoma and abdominal contours as the patient
o Excessive scar/adhesion formation; excessive weight gain.
changes position.
o Poor fixation of the bowel to the fascial layer; a short
mesentery.
o Inadequate length of the stoma (Black, 2009; Butler,
2009).
o Recurrent malignancies (Black, 2009).
o Radiation damage to the bowel or mesentery (Black,
2009).
o A fatty mesentery and well developed panniculus (Shabbir
& Britton, 2010).
Potential complications (Kann, 2008):
• Leakage of the pouching system; peristomal skin irritation; a
mucocutaneous separation; stomal stenosis.
Description
Nursing Intervention
Prevention
• Encourage patients to manage their weight to avoid
stomal retraction and the associated pouching
difficulties and complications which can result
(Arumugam et al., 2003).
Management
• Evaluate the pouching system (Butler, 2009).
• Consider use of convexity, a belt, skin barrier rings,
strips, or paste (Butler, 2009).
• Consider use of a custom-made silicone or rigid
faceplate.
• Consider use of a liquid skin barrier film.
Patient/caregiver education
• Teach the patient skin care and pouching procedures.
• Encourage the patient to attain/maintain ideal body
weight.
Refer to the primary healthcare provider
• A complete mucocutaneous separation that is
accompanied with retraction of the stoma below the
fascia, which is considered a surgical emergency (Kann,
2008).
• Recurrent pouching difficulties, which may require
surgical revision to advance the bowel and create a
budded stoma (Black, 2009).
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STENOSIS
Assessment
Nursing Intervention
Definition
Identifying characteristics
Prevention
• Stenosis is a narrowing or contracting of the stomal • With stenosis there is a small, narrow opening in the • Maintain a secure pouch seal to prevent skin irritation.
opening that may occur at the skin or fascial level.
stoma, which impairs drainage from the stoma.
• Promptly treat hyperplasia by cauterization with silver nitrate
o It is considered an early complication (Butler,
(may require a written order), and make modifications in the
2009), but it can also be a late stomal complication
pouching system to ensure that fecal or urinary drainage does
(Husain & Cataldo, 2008).
not come into contact with the peristomal skin (Butler, 2009).
• Avoid routine dilation of the stoma (Butler, 2009).
• Maintain adequate hydration (Butler, 2009).
Contributing factors/risks
Assessment parameters
Management
• Alkaline encrustation in urinary stomas.
• Perform a gentle digital examination using a
• For fecal stomas, stool softeners, laxatives, and low residue
lubricated, gloved finger to assess the size and
diets may be needed for stool to pass through the narrowed
• Excessive scar tissue formation at the skin or fascial
mobility of the skin and fascial rings (Butler, 2009;
opening (Butler, 2009).
level due to repeated dilation of the stoma or keloid
Colwell et al., 2004).
• Surgery may be needed for severe complications (Butler,
scars.
o If it is not possible to perform a digital
2009).
• Epithelial hyperplasia (Black, 2009; Butler, 2009).
examination, a small, rubber catheter can be used
• Inadequate excision of the skin during construction
to conduct a retrograde contrast study (Butler,
of a stoma.
2009; Colwell et al., 2004).
• Inadequate suturing of the fascial layer.
o If further testing is indicated, such as a retrograde
• Mucocutaneous separation.
contrast study, refer to a surgeon.
• Peristomal sepsis (Butler, 2009).
• Observe for signs of stomal obstruction:
• Prior irradiation of the bowel segment.
o Fecal diversions.
 Abdominal cramps; episodes of diarrhea;
• Recurrent disease (e.g., cancer, Crohn’s disease, or
excessive and loud flatus; explosive passage of
tumor growth).
stool; narrowed caliber of stool.
• Recurrent episodes of skin irritation.
o
Urinary
diversions.
• Stomal ischemia, necrosis, or retraction (Butler,

Decreased
urinary output; flank pain.
2009; Kann, 2008).
 Evidence of high residuals of urine in the
conduit such as urine passing from the stoma in
a projectile fashion, or when catheterized, large
amounts of urine immediately passing from the
stoma.
 Recurring urinary tract infections.
Potential complications
Patient/caregiver education
• Stricture that acts as a mechanical obstruction
• Teach the patient skin care and pouching procedures.
(Bafford & Irani, 2013).
• Urinary Diversion: Instruct the patient about the
signs/symptoms of urinary tract infection.
• Fecal Diversion: Teach the patient strategies to prevent
constipation.
Refer to the primary healthcare provider
• Symptoms of partial or complete obstruction, which may
require surgical revision.
Description
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Research Recommendations
A search of the literature revealed that the evidence base for stomal complications and the management consists primarily of expert opinion. Further descriptive or
exploratory research studies are needed to address the following areas:
•
•
•
•
•
•
•
•
•
Evaluate the technique, complications, reliability and validity of findings of the mini-endoscopy technique (i.e., test tube procedure) for assessing stomal
necrosis.
Describe the characteristics of patients who develop peristomal hernias.
Describe the efficacy of various pouching systems to manage peristomal hernias and mucocutaneous separations.
Determine nursing measures that can help prevent peristomal hernias.
Determine if routine dilation is effective to manage stomal stenosis, or if the procedure contributes to the development or worsening of stenosis.
Describe the effectiveness of vitamin C tablets or cranberry juice to acidify urine or reduce the occurrence of encrustation.
Identify if there are any specific long-term activity restrictions that can reduce the incidence of stomal prolapses and peristomal hernias.
Describe the efficacy of cold compresses or sugar to facilitate manually reducing stomal prolapses.
Identify if the early use of convexity contributes to the development of mucocutaneous separations.
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Glossary
Calcium alginate: A non-woven, non-adhesive wound care product derived from seaweed.
Fascia: Fibrous connective tissue.
Flange: The rigid ring on a two-piece skin barrier/wafer onto which the pouch snaps.
Hernia: A protrusion of any viscus from its surrounding tissue walls. Hernias are classified by anatomic location, contents of the hernia, and whether the hernial
contents are reducible, strangulated, or incarcerated (Byars, 2011).
Hydrofiber: A nonwoven, cotton-like wound care product made of carboxymethylcellulose fiber.
Hyperplasia: An overgrowth of tissue.
Incarcerated hernia: A hernia that is firm, often painful, and non-reducible by direct manual pressure hernia (Byars, 2011).
Melanosis coli: Discoloration of the colon due to chronic use of anthraquinone laxatives containing aloe, senna, and cascara components, which occur naturally in
plants. These laxatives are poorly absorbed. When used chronically, they produce a characteristic brown pigmentation of the colon known as “melanosis coli”
(McQuaid, 2012).
Reducible hernia: The hernial sac is soft and easy to replace back through the hernia neck defect (Byars, 2011).
Slough: Moist brown, gray, yellow, or tan necrotic tissue that may appear mucus-like, thin, or stringy.
Strangulated hernia: The hernia presents with severe, exquisite pain at the hernia site, often with signs and symptoms of an intestinal obstruction, a toxic
appearance, and, possibly, skin changes overlying the hernial sac. A strangulated hernia is an acute surgical emergency. Strangulation develops as a
consequence of incarceration and implies impairment of the arterial or blood flow (Byars, 2011).
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References
Arumugam, P. J., Bevan, L., Macdonald, L., Watkins, A. J., Morgan, A. R., Beynon, J., & Carr, N. D. (2003). A prospective audit of stomas--analysis of risk
factors and complications and their management. Colorectal Disease, 5(1), 49-52.
Bafford, A. C., & Irani, J. L. (2013). Management and complications of stomas. The Surgical Clinics of North America, 93(1), 145-166.
doi:10.1016/j.suc.2012.09.015
Black, P. (2009). Managing physical postoperative stoma complications. British Journal of Nursing, 18(17), S4-10.
Boyd-Carson, W., Thompson, M. J., & Boyd, K. (2004). Mucocutaneous separation. Clinical protocols for stoma care: 4. Nursing Standard, 18(17), 41-43.
Butler, D. L. (2009). Early postoperative complications following ostomy surgery: A review. Journal of Wound, Ostomy and Continence Nursing, 36(5), 513-9;
quiz 520-1. doi:10.1097/WON.0b013e3181b35eaa
Byars, D. (2011). Hernias in adults: Introduction, in tintinalli’s emergency medicine: A comprehensive study guide (7th ed.). Retrieved June 18, 2013 from
http://accessmedicine.com/content.aspx?aid=6361466
Carlsson, E., Gylin, M., Nilsson, L., Svensson, K., Alverslid, I., & Persson, E. (2010). Positive and negative aspects of colostomy irrigation: A patient and WOC
nurse perspective. Journal of Wound, Ostomy and Continence Nursing, 37(5), 511-6; quiz 517-8. doi:10.1097/WON.0b013e3181edaf84
Colwell, J. C., Goldberg, M. T., & Carmel, J. E. (2004). Stomal and peristomal complications. Fecal & urinary diversions: Management principles (pp. 308-325).
St. Louis, MO: Mosby.
De Raet, J., Delvaux, G., Haentjens, P., & Van Nieuwenhove, Y. (2008). Waist circumference is an independent risk factor for the development of parastomal
hernia after permanent colostomy. Diseases of the Colon and Rectum, 51(12), 1806-1809. doi:10.1007/s10350-008-9366-5
Franz, M. G., Robson, M. C., Steed, D. L., Barbul, A., Brem, H., Cooper, D. M.,...Wound Healing Society. (2008). Guidelines to aid healing of acute wounds by
decreasing impediments of healing. Wound Repair and Regeneration, 16(6), 723-748. doi:10.1111/j.1524-475X.2008.00427.x
Fulham, J. (2008). Providing dietary advice for the individual with a stoma. British Journal of Nursing, 17(2), S22-7.
Grant, M., McMullen, C. K., Altschuler, A., Hornbrook, M. C., Herrinton, L. J., Wendel, C. S.,...Krouse, R. S. (2012). Irrigation practices in long-term survivors
of colorectal cancer with colostomies. Clinical Journal of Oncology Nursing, 16(5), 514-519. doi:10.1188/12.CJON.514-519
Hatton, S., & Brierley, R. (2011). Irrigation as an option for stoma management. Gastrointestinal Nursing, 9(7), 6-7.
Heo, S. C., Oh, H. K., Song, Y. S., Seo, M. S., Choe, E. K., Ryoo, S., & Park, K. J. (2011). Surgical treatment of a parastomal hernia. Journal of the Korean
Society of Coloproctology, 27(4), 174-179. doi:10.3393/jksc.2011.27.4.174
Husain, S. G., & Cataldo, T. E. (2008). Late stomal complications. Clinics in Colon and Rectal Surgery, 21(1), 31-40. doi:10.1055/s-2008-1055319
WOCN® National Office ◊ Mount Laurel, NJ 08054
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Kann, B. R. (2008). Early stomal complications. Clinics in Colon and Rectal Surgery, 21(1), 23-30. doi:10.1055/s-2008-1055318
Maeda, K., Maruta, M., Utsumi, T., Sato, H., Masumori, K., & Aoyama, H. (2003). Pathophysiology and prevention of loop stomal prolapse in the transverse
colon. Techniques in Coloproctology, 7(2), 108-111. doi:10.1007/s10151-003-0020-x
McQuaid, K. R. (2012). Drugs used in the treatment of gastrointestinal diseases, in basic & clinical pharmacology, 12th ed. Retrieved June 18, 2013 from
http://www.accessmedicine.com/content.aspx?aID=55832807
Perston, Y. (2010). Ensuring effective technique in colostomy irrigation to improve quality of life. Gastrointestinal Nursing, 8(4), 18-22.
Randall, J., Lord, B., Fulham, J., & Soin, B. (2012). Parastomal hernias as the predominant stoma complication after laparascopic colorectal surgery. Surgical
Laparoscopy, Endoscopy & Percutaneous Techniques, 22(5), 420-423.
Ratliff, C. R., Scarano, K. A., Donovan, A. M., & Colwell, J. C. (2005). Descriptive study of peristomal complications. Journal of Wound, Ostomy and Continence
Nursing, 32(1), 33-37.
Rolstad, B. S., & Beaves, C. (2006). 2006 update: Principles and techniques in the use of convexity. Retrieved 2013 from
http://www.hollister.com/us/files/case_studies/907634.pdf
Shabbir, J., & Britton, D. C. (2010). Stoma complications: A literature overview. Colorectal Disease, 12(10), 958-964. doi:10.1111/j.1463-1318.2009.02006x
Thompson, M. J. (2008). Parastomal hernia: Incidence, prevention and treatment strategies. British Journal of Nursing, 17(2), S16-S20.
Varma, S. (2009). Issues in irrigation for people with a permanent colostomy: A review. British Journal of Nursing, 18(4), S15-8.
Williams, J. (2011). Principles and practices of colostomy irrigation. Gastrointestinal Nursing, 9(9), 15-16.
Wound, Ostomy and Continence Nurses Society. (2005). Stoma complications: Best practice document for clinicians. Retrieved 2013 from
http://www.wocn.org/?page=StomaCompsClinician
Wound, Ostomy and Continence Nurses Society. (2007a). The WOCN image library. Retrieved 2013, from http://www.wocn.org/page/ImageLibrary
Wound, Ostomy and Continence Nurses Society. (2007b). Convex pouching systems: A best practice document for clinicians. Mount Laurel, NJ: Author.
Wound, Ostomy and Continence Nurses Society. (2010). Management of the patient with a fecal ostomy: Best practice for clinicians. Mount Laurel, NJ: Author.
Wound, Ostomy and Continence Nurses Society. (2011). Peristomal hernia: Best practice for clinicians. Mount Laurel, NJ: Author.
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Appendix
Images of Stomal Complications
Figure 1. Peristomal Hernia; Wound, Ostomy and Continence Nurses Society, 2007
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Figure 2. Stomal lacerations; Wound, Ostomy and Continence Nurses Society, 2007
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Figure 3. Mucocutaneous separation, Wound, Ostomy and Continence Nurses Society, 2013
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Figure 4. Necrosis, Wound, Ostomy and Continence Nurses Society, 1997
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Figure 5. Prolapsed stoma; Wound, Ostomy and Continence Nurses Society, 2007
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Figure 6. Retracted stoma; Wound, Ostomy and Continence Nurses Society, 2007
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Figure 7. Stenosis; Wound, Ostomy and Continence Nurses Society, 2007
Acknowledgment about Content Validation
This document was reviewed in the consensus-building process of the Wound, Ostomy and Continence Nurses Society known as Content Validation, which is
managed by the Center for Clinical Investigation.
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