STOMA MANAGEMENT

Dr.v.v.narasimha rao

WHAT IS STOMA ?
stoma is an artificial opening
made in the intestines or urinary
tract to divert faeces,flatus,and urine
to outside the abdomen where they
can be collected in an external
appliances.

 TYPES:

ILEOSTOMY

COLOSTOMY

CUTANEOUS URETEROSTOMY

VESICOSTOMY

ILEAL URINARY CONDUIT

 INTESTINAL STOMAS: ileostomy and colostomy

can be divided into

TEMPORARY

PERMANENT
Can be

LOOP

END

DOUBLE BARREL

ILEOSTOMY
TEMPORARY (loop or end or double
barrel):
INDICATIONS:

colorectal cancer

gangrenous bowel resection

ILEOSTOMY
PERMANENT:(end ileostomy)

crohns disease

ulcerative colitis

familial adenomatous
polyposis

total colonic hirschprungs

disease

COLOSTOMY
TEMPORARY:

perforation of left sided colon

left sided colonic growth

high anal fistula

trauma to left sided growth

sigmoid volvulus

anorectal malformations

congenital megacolon

COLOSTOMY
PERMANENT:

abdomino perineal resection

for carcinoma of rectum
carcinoma of anal canal
after Hartmanns operation

COLOSTOMY
It can be:

DIVERSION COLOSTOMY

DECOMPRESSION COLOSTOMY

blow hole procedure

tube caecostomy

loop transverse colostomy

IRRIGATING COLOSTOMY

STOMA CARE
Starts before the operation and
required till reversal or lifelong
Trained personnel rather than
Surgeon is ideal for stoma care

 Intestinal Stoma Care

Preparation
Post operative care
Follow up care
Patient +/- Family Education

BEFORE OPERATION

Counseling with reassurance

Lifestyle
Site selection and Marking
Education (Patient and Family)
Interaction with stoma community

POST OPERATIVE PERIOD

Stoma health
Stoma function
Stoma complication
Re-operation & Re-fashioning when
appropriate

Post op Stoma
characteristics
Rose to brick red mucosa : Normal
Pale : Anemia
Blanching, dark red or purple: Ischemia
(adhesions, low flow states, or
excessive tension)
Black : Necrosis
In cases of anticipated problem:
8 hourly assessment and
documentation

Diet
Colostomy : no restrictions
Ileostomy : avoid things that may
obstruct
Eating at regular intervals, chew well
and drink adequate fluids
Avoid overeating and excessive
weight gain

Diet: Avoid
Stringy, high fiber foods like celery,
coconut, corn, coleslaw, the
membranes on citrus fruits, peas,
popcorn, spinach, dried fruits, nuts,
pineapple, seeds, fruit and vegetable
skins
Fish, eggs, beer, and carbonated
beverages can cause excessive foul
odor

WARNINGS:CONTACT
SURGEON/NURSE

Foul odor: lasting more than a week

Fever
Skin around gets red and irritated
Size of Stoma changes
Irregular bowel movement
Nausea, vomiting, pain cramping,
bloating

Warning: Urgent Advice if..

Bowel are black or bloody

Bleeding not controllable
Too weak to stand up
Severe abdominal pain

Managing Odor

Fresh persley, Yoghurt, Buttermilk reduce odor

Odor proof plastic pouch
Regular cleaning and emptying
Check leakage
Odor neutralizing sprays
Bags with built-in charcoal filters
Tablets that eliminate the odor:
Activated Charcoal
Chlorophyllin Copper

Bismuth Subgallate

Skin Problems
Faecal dermatitis
Contact dermatitis from occlusive
appliances
Allergic response to adhesive
Fungal/bacterial infection
Peristomal psoriasis
Peristomal intestinal Crohns
Pyoderma Gangrenosum in UC

OTHER COMPLICATIONS

PROLAPSE(MOST COMMON)
RETRACTION
ISCHAEMIA
STENOSIS
PARASTOMAL HERNIA
FISTULA FORMATION
I NFECTION
BLEEDING

Advices on Activities
Plan activities after consultation
Travel: Extra ostomy supplies, liaise
with supplier for arrangement of
appliances
Sports: empty before and use extra
support
Sexual Activities: empty the bag
and use extra support
Swimming: Empty and use extra
adhesive tape at the edge

Type of appliances

ONE PIECE
TWO PIECE
DRAINABLE
CLOSED
CLEAR
OPAQUE

CONVEX

Choice depends on

Type of effluent
Physique of patient
Potential for skin problem
Physical dextirity
Patient preference
Cost

Appliances
Belts
Adhesive strips
Cohesive seals
Convex rings
Adhesive removers
Skin protectors
Fillers pasted
Deodorising sprays
Gel capsules

What about the pouch?

The opening should be 1/8 in larger
than stoma
Empty when1/3 full
Cleanse the pouch from the bottom
with a squeeze bottle filled with
water (one piece unit). The two
piece unit can be snapped off,
washed and snapped back on.
Change the entire unit (1/2 piece)
every 4-7 days depending on
stability of seal

 First at Surgery
Then 2-4 days post-op when starts
working
Initially mucus and serosanguinous
fluid
Flatus and fecal drainage: With
Peristalsis

Empty if required
Remove soiled appliances
Wash and dry stoma and skin
Apply new appliance from bottom up
Dispose of soiled equipment

Dark green To yellowish brown when eats

Output can range 1000-1500ml/24 hours
It decreases within 10-15 days to 800 ml/day
Check fluid electrolyte balance
Low roughage diet, chewed well
Avoid stringy, fibre foods
Vitamin B12 very 3 months If terminal ileum is
removed
Patients need vitamins A, D, E & K (colectomy)
Bleeds easily when touched

If Blocked
Knee-chest position and gentle
massage on the area below the
stoma.
Warm tub bath to relax abdominal
muscles
Replace pouch with one that has a
larger opening
May take fluids only as long as not
vomiting and passing some stool
If vomiting or not passing stool, take
nothing by mouth and contact
Nurse/Doctor

Patient Teaching
The first step is looking at the stoma,
progressing to assisting with
emptying and cleaning, and then to
changing the pouch.
If the patient cannot progress to the
point of willingness to learn, a
caregiver must be taught pouch
change procedure and care until the
patient is ready to learn

Change of Bag
Best before eating (less active
stoma)
Ideally every 5 to 7 days (leak :
Change of Bag
change)

Routine Skin Care

Proper method for pouch removal
Gently peel pouch away from the
skin while pressing down on or
supporting the skin
Avoid wiping the area with paper
towels or toilet paper that leave a lot
of lint behind

 Routine wash with warm water

Soap leaves residue causing
dermatitis and decrease the
adhesiveness of the pouch
If soap is used avoid ones with oils
and rinse thoroughly
Commercial cleansing wipes are
convenient when away from home as
long as they dont contain lanolin or
emollients

Shaving
Shave hairy peristomal skin to
prevent folliculitis and pain with
pouch removal

More considerations
Avoid lifting >10 Ib in first 6 to 8
weeks

And Finally
Before your patient is discharged
they should be able to
Demonstrate cleaning and changing the
pouch
Verbalize where to obtain supplies
Know how to contact a resource person
for problems
Know how/when to follow up with
surgeons and support group.

THANK U

VV
NARASIMHA RAO