Mastery of Surgery
5th Edition

132
Care of Stomas
Laurie Maidl
Jill Ohland
This chapter will provide an overview on the management of ostomies. An intestinal stoma can be a life-altering event for many individuals. The location of the stoma on the abdomen, stoma construction, and appropriate appliance management are all key factors in the adjustment of the person with an ostomy.
Role of the Wound, Ostomy, and Continence Nurse
Ostomy surgery significantly alters bowel function, necessitating physiologic and psychosocial adaptation. A wound, ostomy, and continence (WOC) nurse is a specialist who assists the patient and family with ostomy care during their adjustment to life with an ostomy. In the preoperative setting, the WOC nurse discusses the surgical procedure and lifestyle issues with the patient and his or her family, demonstrates various types of ostomy appliances, and marks the stoma site on the patient’s abdomen.
Postoperatively, in the hospital, the WOC nurse assists the patient to learn management of the stoma using an appropriate ostomy appliance. Dietary advice, peristomal skin care, and resuming activities of daily living are discussed. Rehabilitation, focusing on body image, sexuality, and return to normal life activities such as work or school, is also discussed.
After hospital discharge, it is important for the patient to have regular contact with a WOC nurse to assist in management changes that may occur. These changes may include a decrease in stoma size, changes in body contour, stabilization of weight after surgery, and increasing activity with return to normal lifestyle. The adjustment to a fecal diversion occurs over time. In the years following ostomy surgery, the WOC nurse is available to assist with problem solving of peristomal skin complications, ostomy appliance management difficulties, and psychosocial concerns. In addition, this allows the patient to remain current with ostomy appliances that are available.
Stoma Construction
A stoma may be constructed as an end, loop, or double-barrel stoma. An end stoma is created by dividing the bowel completely. The proximal end of the bowel is brought up to the abdominal wall at the premarked stoma site, everted, and sutured to the skin. The distal portion of the bowel may be removed or may be closed and left in the abdomen. If the bowel is left in the abdomen, the option of reanastomosis could be addressed at a future date. If any portion of bowel is left distal to the stoma, the patient will occasionally expel a mucous drainage per the anus. The mucous drainage is normal and will continue for as long as the patient is diverted.
A loop stoma is created by bringing a loop of bowel, either small or large intestine, to skin level. The bowel is partially divided and both openings are sutured to the abdominal wall. The proximal bowel may be everted and the distal bowel sutured below the proximal stoma. The distal bowel opening would represent a mucous fistula. Mucous discharge would come from the distal stoma opening as well as the anus during the time the bowel is diverted. Management of the stoma may be more difficult with the flush distal loop as mucus is secreted and can undermine the appliance edge, resulting in skin irritation and appliance leakage. The appliance opening would need to be fit to allow both stomas to empty into the pouch.
A double-barrel stoma is similar to a loop stoma, except that the bowel is completely divided and both ends of the bowel are brought to the abdominal wall and matured. The proximal stoma is the functioning stoma and the distal stoma secretes mucus. The stomas may be placed close together and pouched in one appliance opening, or they may be placed at different sites on the abdomen. If they are placed at different sites, there should be at least 4 in. between the two stomas to allow for an adequate pouching surface. The proximal stoma would always be managed with an appliance. The distal stoma may be managed with a pouch initially, and if the amount of mucus decreases significantly, it may be possible to manage this stoma with a gauze dressing. It is important for the patient to know that there will always be some type of discharge from the distal stoma, even though the bowel is diverted.
When a stoma is constructed, it is important that it protrudes above skin level at least 2 cm. This would be true even with a descending or sigmoid colostomy. The stoma will be edematous for 6 to 8 weeks after surgery and will decrease in diameter
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as well as length during this time. As the stoma decreases in size, one that is adequately budded at the time of surgery should still have adequate protrusion when the edema resolves. Ideally the lumen of the stoma would be central, which would allow the effluent to empty into the pouch. If a stoma is flush with the skin or if the lumen empties near skin level, the effluent can undermine the appliance seal, causing appliance leakage and skin irritation.
Types of Stomas
Stomas typically managed with a pouching system are jejunostomy, ileostomy, colostomy, and urostomy. The anatomic location of the stoma provides information about the amount, consistency, and frequency of the output. This information will be used when choosing an appliance to manage the stoma.
A jejunostomy is an opening into the jejunum, which is the midportion of the small intestine. Crohn disease, trauma, or extensive bowel resections may result in a jejunostomy. There is a large amount of intestinal secretions from the jejunum, which aid in digestion. Therefore, the effluent from a jejunostomy is watery, clear, and dark green in color and usually begins within 48 hours after surgery. The volume of output can be over 2 L per day, so it is necessary to monitor the fluid and electrolyte balance for these patients. In addition, the absorption of nutrients, fluids, and electrolytes may be radically reduced in the patient with a jejunostomy. Absorptive capacity of the jejunum depends on the length and function of the proximal bowel. Therefore, nutritional management with hyperalimentation is not uncommon with jejunostomy patients.
An ileostomy is created from the ileum, or the distal portion of the small intestine. The most common reasons for an ileostomy are ulcerative colitis, Crohn disease, and familial polyposis. The initial effluent from an ileostomy usually begins within 48 to 72 hours after surgery and is liquid, but may thicken to a mushy consistency once the diet is advanced. In the first few weeks after surgery, the ileostomy output may exceed 1 L per day, resulting in the need to closely monitor fluid and electrolyte balance. Over time, the small bowel adapts and will absorb more fluid, reducing the volume of output to 500 to 1,000 mL and resulting in thicker stool. The consistency of the output will vary from day to day, depending on the amount of water in the stool.
A colostomy is an opening into a portion of the colon. A colostomy may result from cancer, diverticular disease, volvulus, incontinence, congenital anomalies, or trauma. A stoma may be created in any section of the colon, although cecal and ascending colostomies are rare. The output from the colostomy varies, depending on the stoma location. The more distal the location of the stoma in the colon, the thicker and less frequent the output from the colostomy is. Stoma function also is dependent on the extent of previous bowel resections, residual disease, medications, diet, and concurrent therapies, such as chemotherapy or radiation therapy.
A urostomy is an opening into the urinary tract. Cancer is the most common diagnosis resulting in a urostomy, but incontinence, interstitial cystitis, and congenital anomalies are also reasons a urostomy may be created. An ileal conduit, colon conduit, and ureterostomy are three types of incontinent urostomies and would require an ostomy appliance to contain the urine. The normal output of urine per day is dependent on fluid intake, but is about 1,000 to 1500 mL/d.
Preoperative Teaching
Health care and the recovery from colon and rectal surgery have dramatically changed in the past years. Hospital stays are decreased, early discharge with follow-up care in the home is on the rise, and insurance coverage and payment restraints affect a person’s ability to control and tailor health care to meet specific needs. All of these factors underline the need to have the patient receive preoperative education. Bass et al. conducted a study that concluded that patients who had preoperative education and stoma site marking by a WOC nurse had fewer stoma complications compared to a group that did not have education.
Preoperative education may include discussion of the proposed surgical option, demonstration of appliances, and description of the type of stoma and how it will be managed. It is helpful to describe the stoma appearance, the usual consistency and quantity of drainage, gas and odor control, diet, fluid and electrolytes, clothing, sexuality, recreation, and return to work.
Stoma Site Marking
There are two factors that are critical to patient satisfaction postoperatively with ostomy care: (a) stoma location and (b) surgeon skill in creating a budded stoma. A poorly sited stoma can increase the chance for appliance leakage and peristomal skin complications, which will further compromise the patient’s adjustment and return to self-care. A well-sited stoma that allows for a secure appliance placement and that does not interfere with activities of daily living will allow the patient to rapidly gain confidence and adjust to life with a stoma.
A stoma site should be determined preoperatively for both temporary and permanent ostomies. Although the stoma may be in place only a few months, difficult appliance management due to poor stoma siting can lead to undue psychologic distress.
There are three factors critical to determining the ostomy site. The location of the site must be (a) within the rectus muscle, (b) outside of abdominal creases and scars, and (c) within the patient’s line of vision. Siting the stoma within the rectus muscle will reduce the risk of hernia formation. Assessment of the abdomen in the supine, sitting, and standing positions is important for detection of changes in body contour. It is also important to have the patient bend at the waist when sitting and standing to evaluate for creases at the site. Bony structures are most evident when the patient is supine. Creases and skin folds are most prominent when the patient is sitting. Visualization of the stoma is very important in being able to return to self-care.
The most commonly accepted practice is to site the stoma on the apex of the infraumbilical bulge using the above three critical factors. Stoma sites in all the abdominal guadrants are shown in Figures 1 and 2. If a midline incision is used, it is best if the stoma can be located at least two to three fingerbreadths (about 2.5 in.) away from the incision, as this will allow for an adequate barrier to be placed around the stoma postoperatively. In the same manner, it is best to stay at least two to three fingerbreadths away from the iliac crest to avoid interference with appliance adherence. There has been much written in the literature about the controversial issue of marking the stoma site below the belt line. While most patients report that an ostomy site located below the belt line is easier to conceal within the clothing, the challenge is to find an adequate site on many patients, especially males, who wear their clothing well below the natural waistline of the body. Sites marked too close to the groin crease, too close to the iliac crest, or outside of the patient’s line of vision are fraught with multiple appliance-fit issues. Often a site within the upper quadrant is preferable to the lower quadrant site if the patient can visualize this site and there is an adequate flat surface to adhere the appliance. Sites located within the natural waistline have a strong tendency to crease toward the umbilicus
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and are not suitable sites for stoma location. To assess for possible creasing of a stoma at a selected site, gently push in and up on the stoma site to visualize the natural tendency of the body to pull back on the bowel. Once the stoma site is located, it should be marked in a manner that will be visible after the surgical scrub. Often the site is marked with an indelible marker and later “scratched” with a sterile needle.
Fig. 1. Stoma site marking.
Fig. 2. Stoma sites in all four abdominal quadrants.
The ileostomy and ileal conduit are usually sited on the right side, whereas the colostomy is usually sited on the left side. Prosthetic devices, such as braces or belts, must also be assessed and the stoma site placed for continued use of these devices. When two stomas, such as a colostomy and ileal conduit, are needed, it is best if the stomas can be located on opposite sides of the abdomen, with sufficient room between them for normal appliance barrier placement. If the rectus muscle needs to be removed for reconstruction reasons, both stomas can be located on the same side, usually one stoma in the lower quadrant and one in the upper quadrant. Adequate peristomal skin margins need to be left around each stoma for placement of the ostomy appliance.
Postoperative Teaching
Ideally, postoperative teaching should be a continuation of the teaching already started preoperatively. Postoperative pain and surgical complications can impair the patient’s ability to learn in the hospital setting. Short education sessions are usually better received than one long education session. Shorter hospital stays are prompting more of the ostomy education to be completed in the outpatient setting. Follow-up visits with a WOC nurse or home care nurse should be scheduled before the patient leaves the inpatient setting.
Educational goals should be set with the patient’s input. Although it is ideal for each patient to learn ostomy care to become self-sufficient, many patients cope by having a spouse or family member initially learn the ostomy care. The patient then learns ostomy care at a later date.
Assessment of the patient/family learning styles and barriers is helpful in setting up an educational plan of care. Priority ostomy education focuses on the patient or family member learning how to empty the appliance and to do an appliance change. Upon discharge, the patient or family
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member should be able to demonstrate an appliance change and how to empty the ostomy appliance. Preoperative teaching, such as diet modification, fluid needs, and activity restrictions, also needs to be discussed.
Fig. 3. Flat skin barrier (A) and convex skin barrier (B).
Many changes occur in the stoma and abdomen within the first 2 to 3 months after surgery. These changes can affect the fit of the ostomy appliance on the abdomen. Also, the person with an ostomy has had some time to become familiar with the management of the ostomy, but may have questions or concerns about how to live a normal life with an ostomy. Teaching can be reinforced, as well as adjustment of the appliance fit and support and encouragement to the person with an ostomy.
Ostomy Appliances
The purpose of an ostomy appliance is twofold: (a) to protect the skin around the stoma from breakdown and (b) to contain the effluent in an odor-proof receptacle. There are numerous products on the market that have been developed to use in ostomy care. Ostomy appliances have three main components that need to be assessed when determining which appliance would work the best: (a) type of skin barrier, (b) type of pouch, and (c) type of pouch closure. The WOC Nurse Standards of Care series states that the average wear time for an ostomy appliance is 3 to 7 days. Generally, patients will change the ostomy appliance one to two times per week.
The skin barrier is the part of the appliance that protects the skin around the stoma. Skin barriers are available in standard wear and extended wear. The difference between these two barriers is in the amount of absorption of the product. The barrier with a delayed absorption provides a longer wear time and is considered extended wear. A stoma that has a high output or liquid output may get a better seal and skin protection with an extended-wear barrier. As a general rule, colostomies use a standard-wear barrier, whereas ileostomies and urostomies use an extended-wear barrier.
A skin barrier may also be flat or convex (Fig. 3). The peristomal skin plane will determine which type of barrier to use. The shape of the skin barrier should mirror the peristomal skin plane. Therefore, if there is retraction of the skin around the stoma, a convex skin barrier may be used. There are many additional skin barrier products that can be used on a skin barrier to provide all types of convexity (Fig. 4).
Fig. 4. Additional skin barrier products for adding convexity.
The skin barrier is available in cut-to-fit and precut options (Fig. 5). If the stoma is not completely round or is changing size in the immediate postoperative period, a cut-to-fit option may be best. For the patient with limited dexterity, the precut option may be used.
Skin barriers also come in paste and liquid forms. Paste is used as a caulk on the back of a solid skin barrier to fill in irregular areas. It should be noted that some pastes contain alcohol, which may cause temporary burning of denuded skin and will usually dissolve in 1 to 2 days due to contact with the effluent. For this reason, paste is not often used. Liquid and powder skin barriers may be used under a solid skin barrier to provide skin care to denuded skin (Fig. 6).
The pouch or “bag” is the part of the appliance that holds the effluent. Pouches are usually made from an odor-proof plastic. They are available in many shapes and sizes, and are either transparent or opaque. A pouch needs to be emptied when it becomes one-third to one-half full of gas or effluent.
The pouches come in three main styles: (a) drainable, (b) urinary, and (c) closed end (Fig. 7). The drainable pouch is used for fecal effluent. The effluent is drained out of the bottom of the pouch without having to remove the appliance from the body. The opening at the bottom is secured with a clamp or closure. The urinary pouch is used for urine and has a tap that can be easily opened to drain the urine from the bottom of the pouch without having to remove the appliance from the body. A closed-end pouch has no opening and must be removed either from the body or from the skin barrier to be
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emptied. This type of pouch is often used with a descending or sigmoid colostomy, when the stool is most often formed. Additional features on pouches may be gas filters, cloth covers, or belts that help secure the appliance to the body.
Fig. 5. Cut-to-fit skin barrier (A) and precut skin barrier (B).
Fig. 6. Powder skin barrier and various types of liquid skin barriers.
Fig. 7. Styles of ostomy pouches: Drainable (A), urinary (B), close ended (C), and a stoma cap (D).
An ostomy appliance can be categorized as either one piece or two piece (Fig. 8). A one-piece appliance has both the skin barrier and the pouch in one unit. This appliance may be more flexible and has a lower profile on the body. A two-piece appliance has a skin barrier or wafer that is separate from the pouch. The two-piece appliance has the advantage in that the stoma can be viewed more clearly when placing the wafer. Also, different types of pouches can be used without changing the wafer (i.e., closed end pouch, opaque pouch, etc.).
A disposable appliance is constructed of a lightweight, odor-proof material and is made to be thrown away after normal use (3 to 7 days). The majority of patients with an ostomy use this type of an appliance. A reusable appliance (Fig. 9) is made from a more durable material (rubber or heavy plastic) and tends to be much heavier, often requiring the extra support of a belt to hold it in place. This appliance often needs additional adhesives to properly seal it to the body. The reusable appliance still needs to be changed every 3 to 7 days, and requires additional maintenance as it needs to be cleaned between each use. A reusable appliance can be more cost effective with long-term use.
Peristomal Skin Care
The skin around an ostomy should look the same after surgery as it did before surgery. Basic principles in the management of peristomal skin are to thoroughly wash and dry the skin before applying a properly fitted appliance. The fewer products used on the skin, the less chance there is for skin problems.
The appliance should be removed carefully from the peristomal skin. When lifting the edge of the skin barrier, it is best to push down on the skin of the abdomen, to pull it away from the skin barrier. Warm water or an adhesive remover may also be used. It is important to wash the skin well with warm water to remove any adhesive remover residue, which may cause skin irritation or prevent the appliance from adhering to the skin.
Fig. 8. One-piece appliance (A) and two-piece appliance (B).
When cleaning peristomal skin, it is best to use only warm water and a soft cloth or paper towel and dry well. If soap or skin cleanser is used, it is important to wash the
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skin well with clear water before applying the appliance in order to remove any residue on the skin. Products containing alcohol should be avoided due to the dehydrating effect on the skin, which may result in flaking, itching, and breakdown of the epithelial layer of the skin. Conversely, products with an oil or petroleum base will leave an oily residue on the skin, which may affect appliance adherence. It is not unusual to notice a small amount of blood on the cloth when washing around the stoma. The bowel mucosa contains small blood vessels and may bleed when the area is cleaned.
Excessive peristomal hair should be removed from the peristomal skin to promote a better appliance seal. Some people shave with an electric razor or with a safety razor, using an ostomy skin barrier powder for a dry shave or mild soap and water for a wet shave. When shaving with a razor, use care not to damage the stoma or skin. Hair also may be clipped close to the skin using a scissors.
Fig. 9. Reusable appliance: Rubber faceplate, double-sided adhesive (secures faceplate to the skin), bead O-ring (which secures the pouch to the rubber faceplate), and urinary pouch.
The practice of using antacids to treat skin irritation is no longer recommended. Antacids alter the pH level of the skin, which may potentiate further skin breakdown.
The best form of skin protection is an appropriately fitted appliance. If skin problems are present, it is important to determine the cause. This is necessary to appropriately treat the skin. The most common cause of peristomal skin irritation is stool in contact with the skin. The appliance opening should be no more than one-eighth in. larger than the stoma.
Skin irritation is treated with a skin barrier powder, which is sprinkled sparingly on the peristomal skin. Any excess powder is brushed off the skin. A non–alcohol-based skin sealant can be applied over the powder to help ensure a good appliance seal. The skin sealants are available in sprays, wipes, or gels. After the skin sealant is dry on the skin, the appropriate size and style of appliance can be applied.
At the first sign of leakage, which may be indicated by itching, burning, or pain at the ostomy site, the entire appliance must be changed. Treatment of peristomal skin breakdown will be further discussed under peristomal skin complications.
Flatus and Odor
A major concern of ostomy patients is the passage of flatus through the stoma. The passage of flatus through the stoma may make noise similar to the passage of flatus through the anal opening. Layers of clothing will help to “muffle” the sound. Causes of intestinal flatus are smoking, chewing gum, use of straws, skipping meals, emotional upset, and gas-forming foods (Table 1). Simethicone can be used to reduce the amount of flatus. A filter on the pouch may reduce the profile of the pouch by filtering the gas while eliminating the odor.
Most of the fecal ostomy pouches are odor proof for up to 7 days. Odor that is apparent from the appliance would be an indicator of leakage under the skin barrier. If the end of a drainable pouch is not properly cleansed, odor can also result. Some foods also increase the odor of the effluent (Table 1). Oral preparations containing chlorophyll (200 to 400 mg) and bismuth subgallate (400 mg) may be used to decrease the odor of the stool in the intestine. In-pouch deodorants are also available to eliminate the odor of the stool in the pouch. The appliance should be changed immediately when odor is detected.
Diet and Fluids
There are no dietary restrictions for a person with an ostomy. Postoperatively, there may be short-term restrictions for 2 to 6 weeks on fibrous foods due to intestinal edema. Colon surgery usually results in 2 weeks of diet restriction, whereas with small intestine surgery the restrictions are increased to 6 weeks. Certain foods have been shown to affect the bowel in various ways (Tables 1 and 2). Manipulation of the diet can assist in “thickening” or “thinning” the stool output, or decreasing gas and odor.
Table 1. Properties of various foods. (By permission of Mayo Foundation for Medical Education and Research. All rights reserved.)
Gas-forming foods Foods that are not digested completely.
Beans Celery Coconut
Beer Corn Dried fruit
Broccoli Green beans Green peppers
Brussels sprouts Lettuce Mushrooms
Cabbage Nuts Olives
Carbonated beverages Peas Pickles
Cauliflower Pineapple Popcorn
Onions Raw vegetables Seeds
Spinach
Skins of fruits and vegetables
Stool-thickening foods Stool-thinning foods
Applesauce Alcoholic beverages
Bananas Grape juice
Breads Heavily spiced foods
Cheeses Prune juice
Pasta, rice, potato (without skin)
Peanut butter (creamy)
Tapioca
Foods that reduce color Foods that cause odor
Buttermilk Asparagus
Yogurt Eggs
Fish
Garlic
Onions
Reminders:
  • Eating more than one food from within a list may intensify the effect on the bowel.
  • Do not eliminate a food from your diet without trying it several times.
  • The stool may appear red after eating beets. Do not mistake it for blood. Broccoli, asparagus and spinach may darken the stool.
  • Check with your physician or dietitian about the need for vitamins and/or mineral supplements.
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Food blockage is most often seen in a person with an ileostomy. A blockage is a mechanical obstruction caused by high residue and poorly chewed food that lodges in the distal small bowel, usually just proximal to the stoma. Symptoms of a food blockage include cramping and abdominal pain, along with watery or no stool output. Stomal swelling and abdominal distention are further signs of blockage. These symptoms may progress to the absence of stomal output with nausea and vomiting.
Prevention of food blockage includes limited intake of high fiber or difficult-to-digest foods, thorough chewing of food, and adequate fluid intake. A warm bath may relax the abdominal muscles to allow the blockage to pass through the stoma. Drinking warm fluids, lying in a knee–chest position, and massaging around the stoma may also be beneficial. If the blockage does not resolve in several hours, or if the person with an ostomy develops significant abdominal discomfort with vomiting, a health care professional should be contacted. A digital examination of the stoma and an abdominal radiograph will be obtained. An ileostomy lavage, the instillation of small amounts of saline into the stoma to dislodge a food blockage, may be necessary.
The balance of fluids and electrolytes is a concern in the patient who has had several bowel resections or a colectomy. Although the small bowel will adapt to the loss of the colon’s absorptive function, decreases in the body’s fluid status caused by diarrhea or emesis can lead to dehydration. Symptoms of dehydration include lethargy, dry mucous membranes, decreased urine output, thirst, and abdominal cramping. Normally, an ileostomy appliance would be emptied four to five times in a 24-hour time period, with a total volume of about 1 L. High output may be defined as emptying a pouch every 2 to 3 hours with a total volume of effluent that significantly exceeds 1 L.
Management of dehydration would include increasing fluid intake and diet modifications, such as the use of thickening foods (Table 2). Patients should drink ten 8-ounce glasses of fluid per day to prevent dehydration. Fluid is better absorbed in the small bowel by drinking small amounts of fluid frequently throughout the day.
If dietary modifications are unsuccessful at decreasing the high fecal output, medications may be used to alter the frequency and consistency of the stool. Antidiarrheal medications, such as loperamide and diphenoxylate, can be taken a 30 minutes before meals to slow bowel motility. Bulk-forming medications, such as psyllium, are used to thicken the stool. The bulk-forming medications should be taken with minimal fluid, usually 4 ounces or less, and any additional intake of fluid should be avoided for 1 hour. Patients must be instructed on proper use of these medications because if taken improperly, bulk-forming medications cause diarrhea.
Patients who have ostomies in the upper ileum or jejunum are at risk for not only electrolyte imbalances, but also deficiencies in protein, calories, and vitamins, especially B12.
Medications
An ostomy may affect the absorption and effectiveness of some types of medications. A pharmacist can aid in identifying potential problems. Because the transit time in the small bowel is quite fast, a person with an ileostomy should use medications that are easily dissolved and absorbed, such as liquids and uncoated or chewable tablets. Time-released medications may be only partially absorbed. After new medications are added, assess if the tablet or capsule passes through the ostomy whole or intact.
Antibiotics can change the normal flora of the digestive tract as well as of the skin. Diarrhea may result, which can lead to dehydration and electrolyte imbalance. An overgrowth of Candida on the peristomal skin may occur with the loss of the normal bacterial growth. Penicillins may cause a musty odor in the urine, which will resolve when the antibiotic is discontinued.
Diuretics can cause dehydration and electrolyte imbalance with a high ostomy output. Electrolyte supplements may be necessary. Liquid and powder potassium supplements can cause diarrhea. Diarrhea may be reduced by dividing the dosages in smaller amounts.
Laxatives should not be used by a person with an ileostomy as electrolyte imbalances can occur.
Certain medications can cause discoloration of the stool or urine. A pharmacist
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can be helpful in identifying these medications.
Table 2. Dietary guidelines. (By permission of Mayo Foundation for Medical Education and Research. All rightsreserved.)
General Guidelines Reason
1. Eat meals at regular times, three or more times daily. 1. Skipping meals may cause more gas production.
2. Eat slowly, and chew all foods thoroughly. 2. Chewing assists the digestive process and reduces the chance of food blockages.
3. During the first six weeks, limit foods which may produce excessive gas, loose stools, or which may be incompletely digested. 3. This will decrease the chance for food blockage and reduce the amount of gas and stool.
4. Include foods in your diet that may help thicken the stool. 4. This helps the food move more slowly through the small intestine.
It also allows better absorption of nutrients and water.
5. Drink adequate fluids (eight to ten glasses per day). Sip fluids slowly throughout the day. 5. Drinking fluids will help replace fluids lost through your ileostomy.
6. Try new foods one at a time. 6. This allows you to determine food tolerance.
7. Monitor how the foods you eat affect the consistency of your stool. 7. This will help you make food choices to manage stool consistency while you have your ileostomy and after the ileostomy is closed.
8. Avoid eating large meals during the first six weeks after surgery 8. This will decrease the chance of food blockage.
9. Eat tender cuts of meat, and chew well. 9. This will decrease the chance of food blockage.
Lifestyle
Patients are often very concerned about the restrictions to their lifestyle once they have an ostomy. Outside of short-term, postoperative lifting restrictions, there are no lifestyle restrictions for a person with an ostomy. Patients are able to resume their normal lifestyle and activities. They should be instructed to carry an extra appliance with them to cover any unexpected occurrences. Bathing is an activity that often evokes worry that the appliance will fall off. Patients can be reassured that a properly fitting appliance will stay adhered during bathing. Patients can also bathe without the appliance and should choose a time of day when the stoma is less active, if possible.
An area in lifestyle that may need further adjustment is clothing use. Most people are able to return to wearing the same clothing as they used before surgery. The critical factor is that the effluent needs to be able to flow to the bottom of the pouch for storage. If clothing restricts the flow of effluent into the pouch, leakage may result. One research study stated that the most common surgical complaint after surgery is the siting of the stoma too close to the belt line. The siting of the stoma is based on body contour and not necessarily clothing; therefore, adjustments in clothing postoperatively may be necessary. The patient should be instructed that a poorly sited stoma can cause problems with appliance fit and adjustment of clothing may be the better option when returning to a normal lifestyle.
Rectal surgery can cause changes in sexual function. It is very important that potential changes in sexual functioning be discussed with the patient preoperatively. Some patients feel too embarrassed to bring up the subject of sexuality; therefore, it is usually up to the physician to broach the subject. Depending on the type of surgery, women can experience loss of vaginal lubrication, infertility, or painful vaginal penetration. Men could experience infertility, impotence, or ejaculation problems. It is important to tell the patient how long the sexual dysfunction could occur or if the dysfunction is expected to be permanent. For some men, a referral for a urology workup may be helpful postoperatively.
Pregnancy is not contraindicated for a woman with a stoma. As the uterus expands, stomal changes can occur (i.e., increased diameter, retraction, or prolapse) and often adjustments to the appliance will be necessary. Often a more flexible appliance is needed.
Psychosocial
A person’s ability to cope with an ostomy is directly affected by educational level, cultural values, self-image, past coping mechanisms, current support systems, and financial resources. It has been estimated that up to 20% of patients with an ostomy will experience a significant psychologic symptom postoperatively. Psychologic symptoms can range from anxiety to depression.
Four risk factors associated with postoperative psychologic problems are (a) cognitive factors, (b) past psychiatric history, (c) problems with appliance leakage and stoma prolapse, and (d) peristomal skin problems. Some patients are better able to learn and perform stoma care after surgery. Confidence with ostomy management builds toward management of other aspects of life.
Patients with an ostomy report psychosocial concerns as the (a) ability to feel they have control of their body, (b) ability to deal with stoma care, (c) impact of living with a stoma and its effects on intimacy and sexual function, and (d) issue of odor and noise control.
It is important to address the psychologic concerns of a patient. Emotional support as well as timely teaching based on the individual patient’s needs should be implemented. If needed, a psychiatric referral may be needed for more intense psychologic support.
Colostomy Irrigation
Colostomy irrigation is a procedure where a tap water enema is given through the ostomy as a way to manage stool passage. A bolus of water (500 to 1,000 mL) stimulates bowel contractions and when performed as a routine procedure every 1 to 2 days will develop into a bowel pattern. It takes about 3 to 6 weeks to establish bowel regulation. A person may also choose to discontinue irrigations at any time with no untoward effects to the bowel.
Colostomy irrigation is not required to maintain bowel function, but it is a way to manage bowel function that may allow the patient to be free of fecal discharge for approximately 24 hours or more. It is also one way of managing constipation. Erwin-Toth and Doughty listed four criteria for being a candidate for colostomy irrigation:
  • Irrigation is only an option for a sigmoid or descending colostomy. Ostomies higher than this may have output too liquid to be regulated.
  • A history of regular, formed bowel movements is a good predictor of
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    success for colostomy irrigation. Diarrhea or irregular bowel movements lend toward unsuccessful bowel control.
  • The patient must be willing to learn and perform the procedure independently.
  • It must be the patient’s choice to perform colostomy irrigation as a method of bowel management.
Colostomy irrigation is contraindicated for people with stoma prolapse or peristomal hernia and for children. It is also a procedure that should be performed by the patient with an ostomy, not usually a significant other or caregiver, unless it needs to be done occasionally for management of constipation.
Pediatric Ostomy Management
The pediatric population requirements for an ostomy mirror those of the adult population, including inflammatory bowel disease, incontinence, cancer, and trauma. An additional category, congenital conditions, is more unique to this population. Congenital conditions include necrotizing enterocolitis, Hirschsprung disease, imperforate anus, prune belly syndrome, cloacal exstrophy, and myelomeningocele.
Care of the pediatric ostomy patient requires not only knowledge of ostomy care, but also knowledge in the areas of family dynamics, physical growth and development issues, and in some cases preterm infant skin care development. When an infant is born with an anomaly that requires medical attention, there is a period of adjustment for the family. Parents experience many emotions, including anger, fear, anxiety, and guilt. Parents may wonder if they did something that may have contributed to the condition of their infant. Also, they may be concerned about how they will be able to care for the child. They will need support, time to discuss their fears, and reassurance that they can care for their child.
A stoma requires an adjustment in body image. For infants, this adjustment is experienced by the parents since they were hoping for the “perfect” baby. Parents will be responsible for the care of the stoma and will need time to learn the care. Many times there may be additional surgeries to correct the physical problem. Parents will need a strong support system and encouragement as they care for their infant.
As the child grows, they will develop their own body image. If parents are accepting of the stoma and encourage the child in a positive manner, the child can develop a healthy body image. It is important to encourage the child to do normal activities, such as going to school, playing sports, and making friends. They want to lead a normal life and work toward independence. A school-age child can do much of the stoma care with some assistance from parents. Encouragement and positive reinforcement will help to promote independence.
Body image is very important for teen patients. They are still trying to develop their own identity. Teaching should be done directly with the teen, with the parents available for assistance and support as needed.
Physical growth occurs most significantly in infants. As the infant grows, there will be changes in the peristomal plane, body contour, and stoma size. The stoma should be measured about every 2 to 3 weeks and the appliance size will need to be adjusted as the infant grows. Physical activity will also increase with age, which can affect the wear time of the appliance. Discussion with parents about these expected changes will help them to understand the importance of contacting a WOC nurse to help with necessary appliance adjustments.
Parents may be concerned that their child is not growing at a normal rate. Physical growth is seldom delayed due to the presence of a stoma. It is helpful for the parents to understand that prematurity, other health problems, and nutrition may impact the child’s development.
Premature infants have a less well-developed epidermal barrier, leaving them less equipped to deal with the outside environment. The preterm infant’s skin is more permeable, and the infant may experience greater absorption to substances in contact with the skin. It is best to use minimal products on the skin and use products designed for infants to prevent increased absorption. The epidermis will usually be matured by about 1 month after birth.
Stoma site marking is not always possible in a newborn, as often the surgery is emergent. If it is possible to mark the site before surgery, there are some general factors to take into consideration. A site placed above the umbilicus will usually grow up with the body and stay in the same relative proximity to bony prominences. A site marked below the umbilicus will usually grow down and also stay in the same relative proximity to bony prominences. In older children and teens, the landmarks used for the adult population should be used.
Urinary and fecal stomas in infants can sometimes be managed with a diaper, depending on the location and output from the stoma. The option of diapering and pouching should both be discussed with the parents. Protection of the peristomal skin is the most important goal for the child with a stoma. If skin protection can be adequately achieved with a diaper, it is certainly an option.
As a child grows and becomes more active, pouching will be necessary to protect the skin and contain the effluent. There is a variety of infant and pediatric appliances available, in one- and two-piece styles (Fig. 10). Usually the appliance needs to be flexible for infants, due to the round contour of the abdomen. The skin barriers are thinner and less aggressive to prevent damage to the skin. This means that the barrier is less durable and usually needs to be changed every 2 to 4 days. Often when a child reaches 5 to 6 years of age, an “adult” appliance can be used.
A two-piece system may be preferred for an infant and toddler. This system allows the pouch to be removed from the body for emptying later and a second pouch to be applied. The flange system can also allow for easier release of gas, since infants produce a large amount of gas. If a one-piece system is used, the appliance can be placed at an angle, toward the hip, which may make it easier for the caregivers to empty. As the child grows, the appliance can be placed with the tail downward, so the child can assist with emptying.
Appliance changes should be scheduled at a time when the infant or child is quiet and happy. Initially, some assistance may be needed as stoma care is being learned and parents are becoming more comfortable with management. It is also important for the support people to learn ostomy care to share responsibility and to provide support for the caregivers.
Potential Complications forthe Pediatric Patient
Dehydration
Dehydration is a potential risk for an infant or child with an ileostomy or high-output stoma. Monitoring the consistency and the amount of output from the stoma can help to identify problems. In addition to stoma output, fluids can also be lost from vomiting and perspiration. Parents should learn to recognize the early signs and symptoms of dehydration, such as decreased urine output, dry mucous membranes, and lethargy.
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Fluids can be replaced using oral electrolyte solutions.
Fig. 10. Examples of pediatric pouches.
Stoma Prolapse and Peristomal Hernia
Stoma prolapse and peristomal hernias are common in infants. They do not have well-developed abdominal muscles to support the stoma. Crying produces increased intra-abdominal pressures, which can force the bowel through the fascial opening, creating a prolapse. Increased intra-abdominal pressures can also stretch the fascial opening to create a hernia. As in adults, the distal stoma, in a loop stoma, is more likely to prolapse.
It is beneficial to discuss these possible complications of hernia and prolapse with parents as it can be very frightening. The parents should be reassured that if the stoma color is red or pink, the stoma is functioning normally, and the infant appears comfortable, the prolapse is not a cause for concern. If the parents note any changes in stoma color or function, they need to seek immediate medical attention. The ostomy appliance should be flexible to fit the changes in abdominal contour and the appliance opening should be large enough to accommodate the prolapse. Parents can also be taught to reduce the stoma prolapse if needed. If the stoma is permanent, surgical intervention to repair the prolapse will be necessary at some point in time.
Skin Irritation
Skin irritation is most often caused by contact of effluent on the peristomal skin. This is usually due to an improperly fitting ostomy appliance, erosion of the skin barrier if the appliance is left in place too long, or skin sensitivity to products being used. The skin irritation can be treated by applying a skin barrier powder to protect the skin and absorb moisture from denuded skin. The most important step is to identify the cause of the skin irritation and correct it.
Teaching for the pediatric patient will involve primarily the parents and their support system. The family should be encouraged to participate in the child’s care and to feel comfortable contacting health care professionals for questions or concerns.
The challenges of participating in the care of a child with a stoma includes working with the family, identifying the developmental age of the child and tailoring interventions to meet those specific challenges, understanding pouching principles that pertain to the pediatric population, and providing a nurturing, supportive environment to the child and family.
Stoma and PeristomalSkin Complications
The primary goal for the person with a stoma is prevention of stoma and peristomal skin complications. Preoperative assessment and stoma site marking, postoperative education, and follow-up visits are helpful in preventing complications. When complications do occur, it is important to identify the cause to initiate the appropriate intervention until the problem is resolved. Follow-up is necessary to determine the effectiveness of the intervention.
Stoma Necrosis
Necrosis of a stoma is due to impaired blood supply to the stoma mucosa. This usually is evident within 24 hours after surgery. Stoma necrosis may result from surgical problems during stoma construction, such as excessive tension on the mesentery, or interruption of the blood supply to the stoma, compromising the blood supply. It can also occur in people with poor systemic circulation or a thick abdominal wall. The necrosis may involve the entire stoma or may involve only a portion of the mucosa. The stoma color will change from purple to gray to black and the surface of the stoma will become dry. As the stoma mucosa sloughs due to the lack of blood supply, there may be a strong odor evident from the tissue sloughing.
Interventions for a necrotic stoma include documenting the mucosa color and assessing the depth of the necrosis. This can be done by inserting a small lubricated test tube gently into the stoma and shining a flashlight into the tube to determine where the mucosa is pink and healthy. The stoma needs to be viable above fascia level to prevent peritonitis. As the nonviable tissue sloughs from the stoma, this tissue can be débrided. This will make it easier to do appliance changes and also reduce the odor from the sloughing tissue. Also, as the stoma mucosa sloughs, the skin edges will contract and may result in stoma stenosis. This may require surgical intervention if the stenosis causes problems with stoma function.
Mucocutaneous Separation
Mucocutaneous separation results when the suture line at the junction of the stoma and skin separates. This can occur when there is an oversized skin opening for the stoma, excessive tension at the suture line, insufficient suturing at skin level, or inappropriate sutures, or with patients who have compromised tissue healing, which may include those with diabetes, those taking high-dose steroids, those with malnutrition, or those receiving radiation therapy. Stoma necrosis can also cause a mucocutaneous separation as the necrotic tissue detaches from the skin.
Erythema or induration proximal to the mucocutaneous junction often precedes mucocutaneous separation. The separation may be partial or circumferential. There may be drainage present in the separation, usually serous or purulent in nature. Stool drainage could indicate a possible fistula in the separation.
The separation should be probed gently to determine the depth and access for tracts that may be present. A mucocutaneous separation should not be resutured. The defect can be irrigated gently and then packed with an absorptive wound
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dressing if it is more than 1 cm in depth. Absorptive wound dressings, such as a hydrofiber or calcium alginate, would absorb drainage, prevent excessive soiling of the wound by stool, and promote healing of the separation. If the separation is shallow, the base can be filled with a skin barrier powder to absorb moisture. Once the separation is packed, the skin barrier of the pouching system is placed over the stoma and separation to provide protection from the effluent. It is important to note that the separation will heal even if exposed to stool. As the separation heals, it may be necessary to modify the appliance for improved fit on the peristomal area.
Fig. 11. Stoma retraction: Patient sitting (A) and patient lying (B).
Retraction
Two types of retraction can occur with an ostomy: Stoma retraction or peristomal skin retraction. Stoma retraction (Fig. 11) occurs when the stoma does not protrude above the skin, but has pulled back to skin level or below skin level. It has been reported to occur in as many as 10% to 24% of all stoma patients. Skin retraction (Fig. 12) occurs when the peristomal skin at the mucocutaneous junction pulls in, especially when the patient is sitting or standing. The patient may have a stoma that protrudes 1 to 2 cm or may have a flush stoma, but the skin retracts around the stoma. Retraction may be preceded by stoma necrosis or mucocutaneous separation. It can also result from excessive tension on the bowel due to obesity, edema, distention, inadequate stoma length, or short mesentery.
Evaluation of the stoma may reveal a stoma at or below skin level, although with skin retraction, the stoma may have adequate profile. There may be a receded or dimpled area on the skin due to the tension on the stoma. The stoma should be evaluated with the patient sitting and standing to determine the degree of retraction. Patients will present with problems with appliance leakage, decreased appliance wear time, and skin irritation from stool contact with skin.
The goal for management of stoma retraction is to maintain an adequate appliance seal to prevent effluent from causing skin irritation. This may require the use of a convex appliance, possibly with additional skin barrier rings to increase convexity, depending on the degree of retraction. The use of an ostomy appliance belt or a 4 to 5 in. support belt around the appliance will help to increase the convexity of the appliance and improve the appliance seal. Surgical intervention may be necessary if problems persist.
Stoma Stenosis
Stoma stenosis is described as a narrowing of the lumen of the ostomy at the skin or fascia level. The lumen contracts due to scar formation. Stoma stenosis can occur as a result of insufficient skin excision at the stoma site, excessive scarring due to stoma necrosis, peristomal abscess, or mucocutaneous separation. Significant stenosis can affect normal stoma function, resulting in discomfort when stool passes through the stoma. Also, the patient may experience explosive output with excessive gas as well as decreased caliber of stool.
Digital examination of the stenosed stoma reveals tightness at the skin or fascia opening. The patient with a stenosed colostomy may note symptoms of constipation and increased cramping with stoma function as well as effluent exiting the stoma under pressure.
Management of stoma stenosis would include a low-residue diet and stool softeners for the patient with a stenosed colostomy. This may ease evacuation of stool through the colostomy. Short-term stoma dilation may be performed, but when done over a long period of time, it may cause further stoma stenosis due to scar tissue formation. The ostomy appliance may need to be modified to allow for explosive stool to prevent appliance leakage. If stoma stenosis is severe, surgical revision of the stoma may be necessary.
Laceration (Stoma Trauma)
Stoma trauma or laceration is an injury or cut on the stoma mucosa. This can occur when the appliance opening is too small or is improperly placed over the stoma, with shaving, or as a result of direct injury to the stoma.
A laceration appears as a yellow to white linear discoloration in the mucosa where the injury occurred. Bleeding may occur at the site and there may be blood in the pouch. No pain is evident as there are no nerve endings in the mucosal layer of the bowel.
Management of a stoma laceration is to identify and correct the cause. The appliance
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should be altered to fit the stoma appropriately. If the stoma mucosa is bleeding significantly at the time of appliance change, direct pressure should be applied to the site until bleeding is controlled.
Fig. 12. Skin retraction around a budded stoma: Patient lying flat (A) and patient sitting (B).
Peristomal Hernia
A peristomal hernia occurs when the fascial opening around the stoma becomes larger, allowing protrusion of the bowel or loops of intestine through the opening into the subcutaneous tissue around the stoma. This results in progressive bulging around the stoma. The bulging is usually more prominent with sitting and standing. Although there is no clear identified cause of peristomal hernias, siting of the stoma outside of the rectus muscle may be strongly implicated. They can also occur if there is a large fascial defect; an increase in intra-abdominal pressure, such as with excessive lifting or straining; placement of the stoma through an incision; aging; or excessive weight gain.
Peristomal hernias are visible when abdominal pressure is increased, such as when sitting or standing. The bulging is variable and may be on one side of the stoma or circumferential. Some patients note occasional pain or discomfort in the area of the hernia, which can worsen throughout the day.
Due to the changes in the abdominal contour when lying compared to sitting or standing, patients may experience difficulty maintaining the seal of the appliance. This can result in leakage and skin irritation as well as insecurity with the appliance. Patients who irrigate their colostomy and have developed a hernia may describe unpredictable or poor results with colostomy irrigation. Diagnosis of a hernia can be done by visual examination, having the patient cough or bear down to increase abdominal pressure. Digital examination allows the fascial defect to be felt as well. To confirm the presence of a hernia, a computed tomography scan with oral contrast or an upper gastrointestinal radiograph with small bowel or retrograde contrast study can be done.
Nonsurgical intervention is usually recommended if the patient is asymptomatic. Hernia support belts or binders will provide support around the stoma, reducing the protrusion of the hernia, and can help with appliance adherence. The belt or binder should be put on when the hernia is reduced or when the patient is supine. It is best to use a flexible appliance to fit the changing contour around the stoma. The stoma size should be evaluated when the patient is sitting and standing as it will usually become larger when the hernia protrudes. It is necessary to seek medical attention if the stoma color becomes darker or there is significant pain around the stoma with change in stoma function.
Surgical intervention may include primary fascial repair, local repair with a prosthetic mesh, or relocation of the stoma to the opposite side of the abdomen. Surgeons differ in their preference for surgical intervention with a hernia. Also, the incidence of recurrence following peristomal hernia repair is high. Shellito reported the incidence of recurrence following a local fascial repair without mesh at 76%, a local repair with mesh at 50%, and stoma relocation at 33%.
Prolapse
Stoma prolapse is progressive elongation of the stoma through the skin opening. Prolapse can occur with each of the following scenarios: (a) the stoma has not been placed through the rectus muscle of the abdomen, (b) there is an excessively large opening in the abdominal wall at the time of surgery, (c) insufficient suturing to the abdominal wall, (d) weak abdominal musculature, (e) distended bowel, or (f) increased intra-abdominal pressure, possibly due to distention or crying in infants. Prolapses are seen most commonly in a loop stoma. Although either loop can prolapse, it is seen most often in the distal or nonfunctioning loop. It is important to note that a normal prolapse of 2 to 4 in. is common with stomas and is not considered abnormal or problematic.
The clinical presentation of a prolapse includes a stoma that is increased in size and length, is edematous, bleeds, and is easily traumatized. In severe prolapse, stoma obstruction and ischemia may result due to excessive tension on the mesentery. The stoma will appear dusky or purple. There may also be evidence of tiny ulcerations on the stoma mucosa. Stoma ischemia requires immediate surgical attention.
A prolapse can be managed conservatively if the stoma color and function remain normal. The prolapse may be manually
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reduced with the patient lying flat. Continuous pressure is applied to the distal portion of the stoma, or an ice pack or table sugar can be applied directly to the stoma to decrease the edema and aid in reducing the stoma. A binder or hernia support belt with prolapse flap may be used to keep the prolapse reduced, but in most people these are not effective because they do not apply enough pressure around the prolapse. It is common for the prolapse to recur when the person sits, stands, or coughs, as the intra-abdominal pressure is increased. The pouching system should be flexible, with sufficient length to accommodate the prolapsed stoma. The skin opening in the appliance should fit the stoma when it is at its largest diameter, usually with the person standing. Patients should be instructed to seek medical attention if the stoma becomes dark in color, stoma function decreases or stops, or the stoma becomes painful. Surgery may be necessary to resect the prolapse and revise the stoma.
Fistula
An enterocutaneous fistula is an abnormal communication between the stoma and the surrounding skin. It appears as an opening on the peristomal skin or at the mucocutaneous junction of a matured stoma. Stool may be evident at the fistula site and through the stoma.
Fistulas may occur when a suture is placed through the mucosa of the stoma at the time of surgery, but most commonly are due to recurrence of Crohn disease, poor healing, and mechanical trauma from the appliance being used.
Although some superficial enterocutaneous fistulas will heal spontaneously, surgical intervention may be needed to resolve the fistula. If surgical intervention is delayed or not indicated due to other medical problems, a pouching system that can accommodate both the stoma and the fistula should be considered. If the fistula is located close to the stoma, a convex appliance may provide a better seal for the skin.
Peristomal Skin Complications
Irritant or Contact Dermatitis
Irritant dermatitis of the skin results from contact with a chronic irritant, such as stool or chemicals. This may be due to poor stoma construction causing effluent to be in contact with the skin or from poor technique in appliance care. Effluent may come in contact with the skin if the appliance is not the appropriate size, has not been applied appropriately, or has been left in place too long. Also, if the stoma is located in a poor location or is poorly constructed, this may contribute to leakage and dermatitis. Too many products used on the skin under the ostomy appliance may cause increased interaction of product ingredients, resulting in the development of sensitivity to products.
Skin damage correlates with the area that is exposed to the irritant. The effluent or chemical destroys or erodes the epidermis, resulting in pain and burning of the involved area. The skin initially shows erythema and swelling. It may progress to denudation, ulceration, bleeding, and weeping because of the loss of epidermis.
Treatment is directed at identifying and eliminating the cause. The goal is to protect damaged skin and avoid other irritants. The appropriate pouching system provides a secure, predictable wear time and protects the peristomal skin from effluent. Patch testing of the various products being used can be done to determine if the dermatitis is due to products being used on the skin. This can be done by applying a small amount of the various products being used on the skin, including the skin barrier, pouch, and any skin care products, and labeling them accordingly. The patches are applied to the skin on the abdomen, since it is most similar to the skin under the appliance. The patches should be removed in 48 hours and the sites evaluated for any skin reaction. If a product shows a positive reaction, it should be eliminated. Even after the product is eliminated, it may take several weeks for the reaction to resolve. Topical steroids may be used short term to reduce the inflammation and pain. Skin barrier powder can be applied to the skin to absorb moisture and provide a dry pouching surface.
Candidiasis
Peristomal candidiasis is an overgrowth of a Candida organism of sufficient magnitude to cause an inflammation, infection, or disease on the skin surrounding an ostomy. Candida albicans is the most frequent agent of candidiasis and thrives in dark, moist areas. A leaking ostomy appliance, body perspiration, and denuded skin, caused by too large of an appliance opening or prolonged wear time, all provide optimum environments for candidiasis to develop on the skin. Other predisposing conditions include long-term antibiotic therapy, diabetes mellitus, immunosuppression, myelosuppression, use of oral contraceptives, topical corticosteroid therapy, and iatrogenic hypersteroidism.
Skin manifestations include papules, pustules, erythema, and pruritus. The lesions are extrafollicular, and satellite lesions, extending beyond the edge of the appliance, are common. Candidiasis may also be evident in skin creases, such as the axilla or groin.
Effective treatment of candidiasis begins with identifying the cause and eliminating it. A dry environment may be provided with an appropriately sized appliance, which fits the abdominal contour. Also, porous tapes and pouch covers or gauze under the pouch to absorb moisture may be used. A topical antifungal powder, such as nystatin or miconazole powder, should be applied sparingly to the affected area and rubbed into the skin, with the excess brushed off. This will not inhibit a secure appliance seal and treat the candidiasis. An antifungal powder should be used with each appliance change until the skin is completely clear. It is not recommended to use the powder prophylactically. Extended-wear skin barriers, which absorb moisture and keep the moisture in contact with the skin, may need to be eliminated if candidiasis recurs.
Allergic Dermatitis
Peristomal allergic contact dermatitis refers to hypersensitivity to chemical elements resulting in an inflammatory reaction. Damaged or inflamed peristomal skin is at increased risk for sensitization because the skin’s immune system is overstimulated. The original skin problem may be denudation caused by an irritant dermatitis. The products used to treat the damaged skin may then create an allergic contact dermatitis. Once the sensitivity develops, it can last for months to years.
Management of allergic dermatitis consists of determining and eliminating the causative factors. An allergic dermatitis should be considered when the skin reaction is located in the area where a specific product is being used. Skin patch testing can be done to determine the causative agent. Treatment may also include the use of topical corticosteroids to reduce the inflammation, an appropriately fitting ostomy appliance, and the elimination of any unnecessary products on the skin to prevent further dermatitis.
Mechanical Injury
Damage to the peristomal skin may result from mechanical injury, such as trauma, shear, or pressure. Common causes include
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abrasive cleansing techniques and traumatic tape removal that results in epidermal stripping, shearing of the skin as the appliance moves on the skin, or continued friction or pressure from inappropriately fitting equipment. The affected skin is painful, and the moist, bleeding areas undermine the pouch seal, resulting in frequent pouch changes and further exacerbation of the problem. Lesions are typically shallow and irregularly shaped, and appear as a full- or partial-thickness skin loss located in the area of the trauma.
Mechanical injury can be prevented by educating the patient in appropriate appliance removal, which is gently pushing the skin away from the appliance instead of pulling on the skin. Adhesive removers may be necessary if the skin is thin or sensitive, but it is important to wash the adhesive remover off the skin before applying another appliance to prevent contact dermatitis. The appliance fit should be evaluated to determine if there is excessive pressure, possibly from a convex appliance or belt, especially with changes in body contour postoperatively or with a hernia, that may be causing an ulceration. This may necessitate the use of a softer or more flexible appliance or discontinuing the belt to prevent excessive pressure and promote healing of the ulceration. Skin barrier powder can be used to absorb moisture from the ulcer site, which will improve appliance seal.
Pseudoverrucous Lesions (Hyperplasia)
Pseudoverrucous lesions are raised areas located around the stoma, usually at the mucocutaneous junction. They are thickened epidermal projections with white, gray, brown, or dark red wart-like papules or nodules. These lesions are localized to areas of chronic exposure to moisture, usually stool or mucus, and can be extremely painful and bleed easily. The chronic irritation from moisture causes thickening of the epidermis, which may be due to the use of an appliance opening that is too large for the stoma or from chronic appliance leakage.
The primary treatment of pseudoverrucous lesions is to eliminate chronic exposure of effluent on the skin. The ostomy appliance should be resized to fit within one-eighth inch of the stoma and should fit the abdominal contour appropriately to prevent leakage or effluent undermining the skin barrier. The appliance skin barrier should cover the lesions to protect them from effluent. Silver nitrate may be used on large lesions to hasten healing and provide a flat surface for the pouching system. Appliance change intervals may need to be more frequent during the initial treatment, every 3 days, but once the lesions have resolved, a normal appliance change schedule may be resumed.
Folliculitis
Folliculitis is an infection of the hair follicles, usually caused by Staphylococcus aureus. Erythematous and sometimes pustular lesions are present around a hair follicle, which is helpful in the differentiation of folliculitis from candidiasis. Peristomal folliculitis generally results from traumatic hair removal, which may be the result of shaving hair from the peristomal skin too frequently. Other causes are indiscriminate shaving or dry shaving techniques and friction from careless pouch removal.
Management of folliculitis consists of determining the technique for peristomal hair removal. The patient should reduce the frequency of shaving to no more than once a week and shave lightly or clip the hair with a scissors to prevent skin damage.
Pyoderma Gangrenosum
Peristomal pyoderma gangrenosum (Fig. 13) is a rare, ulcerative skin condition of unknown cause that occurs in the area surrounding the stoma. It may start as one or more pustules that break open and form full-thickness ulcers with irregular, ragged, overhanging margins. A necrotizing inflammatory process extends peripherally from the primary lesion, resulting in a necrotic ulcer with undermined edges. The surrounding skin becomes red and purple, and the entire area is very painful, which may distinguish it from other types of ulcers. Peristomal pyoderma generally does not extend beyond the adhesive edge of the appliance system. Healing typically results in a cribriform scar. Ulcers that result from pressure are often misdiagnosed as peristomal pyoderma gangrenosum. One also must consider cutaneous Crohn disease, in which linear ulcers have undermined violaceous edges.
Fig. 13. Pyoderma gangrenosum.
Peristomal pyoderma usually reflects underlying inflammatory processes rather than being a complication of ostomy construction. Diseases associated with pyoderma include ulcerative colitis, Crohn disease, arthritis, leukemia, polycythemia vera, and multiple myeloma. Diagnosis of pyoderma gangrenosum is a clinical one based on history and ulcer assessment. There are no diagnostic tests. Biopsy only serves to exclude disorders such as malignancy or vasculitis. The principles of management include decreasing the inflammatory process and maintaining the seal on the appliance for a predictable period of time. Screening for the presence of systemic active inflammatory bowel disease should be completed. Topical treatment may include anti-inflammatory agents such as steroid preparations or topical immunomodulators. Systemic medical therapy may be necessary if there is no improvement or worsening of symptoms using topical therapy.
The goals of pyoderma gangrenosum wound care include moisture control, maintenance of a clean wound base, protection of the wound base, delivery of topical anti-inflammatory/immunosuppressive preparations, and achievement of a predictable pouching system seal of at least 24 hours. Shallow ulcers may be filled with a skin barrier powder to absorb moisture and
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promote a secure appliance seal. Hydrofiber or calcium alginate dressings can be applied over the ulcers to contain wound drainage. The frequency of appliance changes will be determined by the amount of drainage. When the ulcers heal, the area around the stoma may be uneven, resulting in the need to refit the pouching system.
Follow-up
Patients with ostomies must receive follow-up care after discharge as the stomas will change during the first 2 to 3 months after surgery. Change in stoma size, body contour, stabilization of body weight, and an increase in activity level may alter the fit of the appliance, making modifications necessary. Psychological support is also useful.
Supplies
Ostomy supplies are available at ostomy supply centers, pharmacies, and medical supply stores, as well as through mail-order companies and online. Many insurance companies will reimburse for a portion or all of the cost of the supplies. The patient should inquire about this through his or her specific insurance agency. A prescription for ostomy prosthetics may be necessary for reimbursement. This is most often provided by the physician or WOC nurse.
Alternative Procedures
Continent Ileostomy (Kock Pouch)
The continent ileostomy (Kock pouch) is an internal pouch with a nipple valve constructed from the distal 18 in. (45 cm) of the ileum. This procedure is performed for patients with chronic ulcerative colitis or familial polyposis. The reservoir initially has a very small capacity. A 28 or 30 French catheter is placed through the nipple valve into the pouch at the time of surgery. The catheter is then clamped or removed from the pouch for increasing periods of time to allow the pouch to expand in size. Over time the capacity of the pouch can increase to hold 500 to 750 mL of stool. The pouch should be continent of gas and stool. To empty the pouch, the catheter is placed in the stoma every 4 to 6 hours. Patients with a continent ileostomy are able to wear a small waterproof pad or gauze over the stoma between intubations. This will absorb mucus from the stoma and protect clothing.
Problems with nipple valve dysfunction often result in the need for reoperation. The development of the ileal pouch–anal anastomosis (IPAA) procedure has resulted in a decreased use of the continent ileostomy as a procedure of choice. The continent ileostomy may still be performed for patients who are not a candidate for IPAA or who have a failed IPAA but would prefer not to wear an external ostomy appliance.
Ileal Pouch–Anal Anastomosis
The IPAA procedure is a procedure performed for people with chronic ulcerative colitis or familial polyposis. The IPAA procedure may be done in one, two, or three stages of surgery. An internal pouch is created from the ileum and sutured above the anus. A temporary loop ileostomy is frequently performed to allow the pouch to heal. The ileostomy is usually closed in 6 to 12 weeks.
Management of the temporary loop ileostomy is usually the most important focus for patients during the 6 to 12 weeks after surgery. Diet and fluid intake to maintain adequate nutrition and hydration are also very important. The loop ileostomy is located more proximal in the ileum, which can result in problems with high ileostomy output and dehydration. Intake of stool-thickening foods and the use of antidiarrheal medications prior to meals can help to reduce ileostomy output and maintain hydration.
Following closure of the ileostomy, when the internal pouch capacity is small, patients need to understand that they will have frequent stools with urgency. They may have up to 10 bowel movements per day initially. The internal pouch will gradually enlarge. As the patient starts to eat solid food, especially stool-thickening foods, the stool consistency will thicken, making it easier for the patient to hold back on the urge to have a bowel movement, increasing the size of the pouch capacity. The internal pouch will gradually adapt over time and after 6 to 12 months the patient may have only two to six bowel movements per day.
Frequent bowel movements and stool seepage between bowel movements can result in perianal dermatitis. Effective perianal skin protection should begin in the immediate postoperative period. After bowel movements, the perianal skin should be washed with a soft disposable cloth and the skin should be dried gently. A moisture barrier ointment is then applied to the perianal skin to protect the skin from stool drainage. Zinc oxide–based barriers are preferred over the petrolatum-based barriers. A protective dressing, such as a fluffed gauze, ARD dressing, or cotton ball, should be placed just at the anal opening. The dressing will absorb drainage to help protect the skin and should be used until there is no drainage between bowel movements.
Overall patient satisfaction following IPAA surgery has been high. The surgery eliminates the disease and the need for a permanent stoma. There is an adaptation phase that can take 6 to 12 months or even longer, and the functional results are not perfect, but patients appear to adapt without being restricted in their daily living.
Conclusion
Any patient with a possibility of needing an ostomy postoperatively should have preoperative education related to ostomy care. Marking the stoma site before surgery ensures that the stoma is in the best position for successful care by the patient. After surgery it is very important to continue ostomy education to fit the patient with an appropriate ostomy appliance. The abdominal contour changes during the postoperative period, so it is necessary to have the ostomy appliance assessed for appropriate fit 1 to 2 months after surgery. Yearly assessment of the ostomy and peristomal skin is needed to prevent ostomy complications that could occur over time. Proper ostomy care is necessary for the physiologic and psychosocial health of the patient.
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