Note: This guideline is currently under review.
Introduction
Aim
Definition of Terms
Assessment
Management
Special Consideration
Evidence Table
References
Introduction
This
guideline applies to all infants returning post-operatively with a stoma.
The conditions that require stoma formation include anorectal
malformations, Hirschsprung disease, intestinal atresias, necrotising
enterocolitis and spontaneous ileal perforation. The stoma formation may be in response to a
single congenital malformation or in the context of a more complex condition or
syndrome. In most situations, the stoma
may be closed prior to discharge from hospital or the patient may be discharged
home with the stoma in-situ.
Post-operative management of the infant will depend on their underlying
condition and the procedure performed and may include monitoring of fluids and
electrolytes, as well as management of nutrition and pain relief. The focus of care will be the successful
reintroduction of enteral feeding. The
success of enteral feeding will be dependent on multiple factors, including the
pre-operative condition and gestational age.
Post-operative complications will relate to wound healing ability,
length and type of gut retained, further deterioration of surviving gut,
stricture formation and risk of sepsis, as well as individual neonatal
characteristics. Each of these may impact
on the infant’s hospital journey.
Aim
- Outline initial
post-operative assessment and management of the newly formed stoma.
- Provide a guide to
dressing changes and bag application
- Outline management of
fluid and electrolyte balance.
- Explain complications
and common problems associated with stomas so that early recognition and
management may be implemented.
- Outline ongoing
management of the active stoma and enteral feeding introduction.
- Explain re-feeding
and procedure for re-feeding.
- Provide pictorial
guidance for infant’s undergoing surgery with a pre-existing stoma.
Definition of Terms
- OSTOMY: surgically
formed opening from the inside of an organ to the outside.
- STOMA: the part of
the ostomy that is attached to the skin.
It is constructed from the (usually) end of the bowel that has been
surgically brought up through the skin and attached.
- ILEOSTOMY: a part of the
small intestine is diverted out through the abdomen. Output is liquid and may look undigested.
- COLOSTOMY: a part of the
colon is diverted out through the abdomen.
Output may initially be meconium becoming yellow and curdy.
- JEJUNOSTOMY: more proximal small
intestine section brought through the abdomen.
Output may be very watery and corrosive.
- MUCOUS FISTULA: the other end
of the non-functioning bowel brought through the abdomen – the distal bowel
end.
- OROGASTRIC TUBE: small plastic
tube passed through the mouth and oropharynx, down the oesophagus and into the
stomach.
- NASOGASTRIC TUBE: small plastic
tube passed through the nare and nasopharynx, down the oesophagus and into the
stomach.
- NASOJEJUNAL TUBE: small plastic
tube passed via the nose, back of the throat, down the oesophagus, stomach and through
the pyloric sphincter into the jejunum.
Types of stomas
- LOOP: a loop of the bowel
is brought through an opening in the abdominal wall, with an opening created in
the apex of the bowel to allow emptying of contents.
- DOUBLE-BARRELLED: usually a
temporary ostomy with two openings, one distal and one proximal. Elimination occurs via the proximal opening,
with the distal portion of the bowel able to rest and heal. When healing is complete, the two ends are
re-anastomosed and returned to the peritoneal cavity with the aim of returning
bowel function.
- HIGH OUTPUT STOMA – any stoma that
produces equal to or >20ml/kg of effluent and required replacement of
gastrointestinal losses to prevent complications.
Assessment
Physical Assessment
Most infants will return postoperatively with Jelonet and gauze over
the stoma. The laparotomy suture line should
have an adhesive dressing over it which should remain intact until surgical
direction to remove.
Stoma observations should occur upon return to ward post-operatively
and at least 4 hourly thereafter.
Observe
COLOUR
- Red stoma/dark pink indicates adequate blood supply/healthy
- Pale pink indicates diminished haemoglobin or poor perfusion
- Dark red/purplish may indicate bruising
- Grey to black indicates ischaemia and potential necrosis – immediate
surgical review required
APPEARANCE
- Healthy - red/pink and moist
- Taut - oedema (oedema will subside over the coming weeks, with actual
stoma size presenting towards the end of week 2)
- Injurious - lacerations may occur due to handling
- Shape – round, oval, irregular
PROTRUSION
- Normal - above skin line 0.5 – 1 cm approximately/protruding
- Flush - at the level of the skin
- Retracted - below skin level
- Prolapsed - protrusion of stoma more than 2-3 cms
MUCOCUTANEOUS JUNCTION (where the
stoma meets the skin)
- Intact– Sutures intact all the way around.
- Separated – an area of stitches has become separated
PERISTOMAL SKIN (the skin
around the stoma)
- Colour - healthy (should be the same as “normal” skin), erythema,
bruising
- Integrity - intact, macerated, eroded, rash, ulcer, incision
- Turgor - soft, elastic, flaccid, firm
WOUND
- Consider wound bed, measurement, edges, exudate, infection, surrounding
skin, pain
- Refer to Wound Care Nursing Guideline if further information required.
Ongoing Assessment
Potential
complications:
Complications that may occur can involve the stoma itself, the surgical
wound or the peri-stomal skin. For
ongoing assessment and handover purposes, the Rover can be used to photograph
the stoma and be uploaded to the Media section of the medical record with
linkage to LDA’s.
- Bleeding stoma – may be
normal, as mucous membranes are very vascular.
Report excessive bleeding, bleeding that does not stop within a
reasonable time frame or bleeding that has been caused by accidental trauma.
- Prolapsed stoma – not able to
be controlled but needs to be monitored.
Document approximate length of protrusion and observe for signs of
reduced perfusion, such as darkening, cooling or drying of the stoma or
progressing prolapse. Report and
document the prolapse to neonatal and surgical medical teams/ANUM/stomal
consultant and in the EMR. There may be
implications for stoma appliance selection once stoma is active.
- Retracted stoma – Report
retraction to neonatal and surgical medical teams/ANUM/stomal consultant. Implications regarding stomal appliance may
exist. Retracted stomas may create issues
around wound and peri-stomal skin integrity as the stoma activity increases.
- Ischaemia/necrosis – an emerging
medical emergency so escalate to the neonatal and surgical teams immediately
for urgent surgical review and report to ANUM/stomal consultant.
- Muco-cutaneous separation – if sutures
separating between stoma and skin, report to medical staff/ immediately so
surgical review may occur and notify ANUM/stomal consultant Skin integrity and wound healing differs
greatly between infants.
- Wound breakdown – document
wound details, including size and depth of opening, colour of surrounding skin,
inflammation contours, exudate and odour.
Refer to wound Care Guideline and report to medical staff and ANUM/stomal
consultant. Dressing modifications and
surgical review may be required.
- Peri-stomal skin breakdown – at any stage
in stoma management, peri-stomal breakdown may require reversion to dressings
if stoma bags cannot be used due to skin integrity breakdown. Notify medical staff/ANUM/stomal consultant
if assessments include deterioration in integrity, turgor and colour of
peri-stomal skin. If required, follow
the procedure for stoma dressing and change 4/24 and prn once soiled.
- High loss stoma – once
feedings have begun, losses will increase.
A high loss stoma will produce >20 ml/kg of effluent in a 24-hour
period and the infant will require replacement of these losses at the time they
reach the 20ml/kg loss. Refer to Replacement of Neonatal G.I losses guideline.
As enteral feeds are introduced, other complications may emerge, such
as pre-stomal obstruction, strictures and feed intolerance for a variety of
reasons that will need medical and/or surgical management. Report to medical staff/ANUM/stomal
consultant episodes of vomiting and changes in output volumes or
appearance. Blood in the effluent is
never normal and must be investigated urgently.
Feed Intolerance symptoms
- Increasing gastric residuals
- Emesis
- Abdominal distension
- Visible loops of bowel
- Altered stool characteristics
Stomal
Therapy
Stomal therapy consultants at RCH are employed by the Department of
Education and Training and receive a referral from the surgical team when a
stoma is newly formed. Nursing staff
caring for an infant with a stoma should ensure this has occurred so the infant
may be followed-up and reviewed as required by the surgical teams.
Stomal Therapy are involved in education for parents and new babies
with stomas and provide the education they require for discharge home safely
and organize their linking in with Ostomy associations.
Stomal therapy should be notified if complications arise and when
advice regarding dressings or product modifications are required. Stomal therapists do not attend routine
dressing or bag changes.
Contact stomal therapy on: Stomaltherapy.Continence@rch.org.au
Phone 3945 5338
ASCOM 52496
Investigations
Infants with stomal losses require frequent and regular evaluation of
their fluid and electrolyte status to prevent complications. Sodium is critical to growth and infants with
ongoing sodium deficits are at risk of impaired growth and cognitive
dysfunction.
Increased sodium losses are associated with high output stomas,
anatomically higher stomas and premature infants.
- Serum electrolyte/urea/creatinine: should be
checked at least daily until stabilized, then weekly until re-anastomosis. More frequent checking may be required dependent
on the infant’s weight gain, stomal losses, age, electrolyte stability and
general condition.
- Urinary sodium: Should be checked weekly. The sample does
not need to be sterile. Normal ranges
vary; however, urinary sodium levels should be maintained between
20-40mmol/L. If infants have poor growth
or high losses, this may need more frequent checking. In infants with good renal tubular
reabsorption, urinary sodium is the best measure of total body sodium and
levels of depletion. However, results may be misleading in preterm infants and
those with renal disease. Do not rely on
serum levels as evidence of total body sodium.
- Sodium supplements: In infants able to tolerate oral medication, 6% sodium (Hypersal)
is the appropriate supplement. A low
urinary sodium (<20mmol/L) is the indication for commencement of supplements.
However, most neonates with a stoma will
require supplementation 2-4 mmol/kg/day. An IV sidearm of Sodium 3% (or 0.9%)
and modification of TPN are alternatives for infants not suitable for oral
sodium supplements.
- Acid base balance: A capillary
sample will be required in any unwell infant who has losses > 20 ml/kg. There may be many other reasons a neonate
requires a Capillary Acid Base sample not directly related to the stoma, for
example, ventilated infants or those with sepsis.
https://www.rch.org.au/neonatal_rch/intranet_Drug_and_electrolyte_dosing_in_the_RCH_NICU/
Management
Patient’s returning post operatively will require 4 hourly dressing
changes at a minimum, moving to 4-6 hourly PRN as assessments and stomal
characteristics change. Several products
are available for use.
PRODUCT DESCRIPTION
- orabase: protective paste that may be used around the
stoma to prevent breakdown or assist with healing if skin broken and weeping.
- ilex: topical
occlusive skin barrier that repels moisture and bacteria. Can adhere to moist, weeping tissue and
severely excoriated skin. This is not
ward stock and should be recommended by a stomal specialist.
- jelonet: primary stoma dressing consisting of paraffin
gauze that prevents secondary dressing adhering to stoma, keeps stoma moist and
allows drainage.
- 1 piece appliance: wafer and bag in one
appliance – default product on Butterfly is dansac wafer and bag.
- 2 piece appliance: separate wafer and bag
that sticks or clips in place. (Require stomal specialist assessment before
provision for permanent stomas in going home infants)
- caulking strips: moldable strips or rings to be softened in
gloved hands and used to “build-up” areas of indentation, scars, defects and
skin creases to increase convexity, create a barrier and decrease the
likelihood of stools seeping into creases and creating loss of wafer adhesion.
- wafers: usually circular and internally cut to stoma
size. May be dansac brand with bag that
attaches or if increased convexity required, use Bravia protective sheet 3210 as
this is more flexible.
- stomahesive: a powder that assists in protection of muco-cutaneous
junction separation, defects and weeping skin.
Forms a protective barrier to surface of stomas and assists with
superficial bleeding.
- gauze: used as a secondary dressing, sterile with minor
absorptive qualities.
- combine: used a tertiary dressing for added absorptive
qualities.
Contact Clinical Technology to supply base products and specialized
products such as 2-piece bag systems and eakin strips/caulking paste can be
obtained by contacting Stomal therapy on ASCOM 52496.
DRESSING
CHANGE PROCEDURE
Inactive stomas or extreme excoriation of peri-stomal skin due to bag
leakage. Aim is to keep the stoma clean and moist and to measure fluid losses
while assessing integrity, healing and identifying emerging complications.
See: Procedure - Inactive
stoma dressing change.
See: Procedure – Active Stoma
bag application procedure.
ONGOING
MANAGEMENT
MANAGEMENT
OF NASOGASTRIC TUBE:
A nasogastric or orogastric tube must be insitu and open to free drainage into a yellow container with an
air escape hole cut into it. Never clamp
the NGT unless directed by the surgical team. When feeding commences, it will
be via this tube and clamping for up to an hour post feed/medication
administration then venting will be appropriate.
Gently aspirate yellow container to form a documented loss every 4
hours until feeding commences. Document
separately as “aspirate” and “drainage” in the Fluid Balance section of the EMR
Flowsheets.
PROCEDURE
FOR BAG APPLICATION/CHANGE:
Introduction of enteral feeds will increase output and require skin
protection with stoma wafer and bag.
Small dantac bags are used with circular wafers and are available by
contacting clinical technology who will arrange supply. However, if increased convexity is required due
to scar indentations Bravia protective sheet 3210 may be cut to size. It is hoped that initially bags can remain insitu for at least 24 hours – 72 hours to
preserve skin integrity. Never reinforce
a wafer as effluent will be on the skin underneath corroding it.
You may wish to angle the new bag so it rests sideways across the
abdomen and can be covered with the nappy.
Bags pointing straight down may become contaminated with urine and may
adversely affect skin integrity and wafer adhesion.
If the wafer and bag are secure with no evidence of leakage, the bag
can be opened from the bottom and using a syringe with white tipped aspirator,
remove contents and document output in Fluid Balance every 4 hours.
NUTRITION:
Patients will require TPN until the stoma becomes active, indicating
returning intestinal function. Feeds
will initially be trophic, increasing at a rate determined by medical
staff. Daily gradings should be assessed
for tolerance and symptoms of feed intolerance reported to the ANUM and medical
team.
REFEEDING:
Follow link: PROCEDURE –
Refeeding
The first NGT
insertion into the mucous fistula is to be conducted by the surgeon or their
delegate. If documented as appropriate,
suitably experienced nurses may insert subsequent tubes to the documented
length.
Education/discharge planning
It is appropriate that parents/carers are educated on the basic care
requirements and identification of stoma complications as often parents are
willing and able to attend to the stoma care needs of their infants while they
are inpatients. Stoma education may
begin as soon as parents/carers are willing to begin. However, it is important to note that not all
parents are willing to participate immediately and will require support to
build confidence.
Parents whose infant is being discharged with a stoma will be required
to learn to care for the stoma before discharge. Care co-ordination and stoma support services
are available for any infant going home with a stoma.
Special Considerations
Special Considerations for Perioperative Stoma Care
New Stoma bags are required to be applied to all in-patients prior to
going to surgery. Refer to procedure for
bag application change as per guideline.
Intra-operative Cardiac Theatre Stoma Care
Hand hygiene performed.
The stoma area will be included in a pre-op wash using 2% Chlorhexidine
Gluconate wash cloth, taking care not to touch the stoma site. A raytec gauze
and large tegaderm are to be used to cover the stoma bag. The patient will then
be prepped and draped as routine for Cardiac Surgery.
Surgical prewash |  |
Application of sterile raytec gauze and |  |
Stoma isolated and sealed from surgical field now ready for surgical prepping and draping | |
Completion of surgical skin preparation and draping | |
Intra-operative General Surgery Stoma Care
Hand hygiene performed.
The stoma bag will be removed prior to scrub and then a pre-op wash using
Cetrimide.
If the procedure is
not to close the stoma, the stoma site will be dressed with a raytec gauze
and large tegaderm will be used to cover the stoma bag after the patient has
been prepped and draped.
If the stoma is to be
close it will remain undressed and surgery to continue.
Related Procedures
Admission
to Neonatal Intensive Care Unit
Neonatal
Pain Assessment
Replacement
of Neonatal Gastrointestinal losses
Neonatal
and Infant skin care
Routine
Post Anaesthetic observations
Nursing
Assessment Guideline
Wound
Care
Parenteral
Nutrition in the Newborn Intensive Care Unit
Drug
and Electrolyte dosing in the RCH NICU
Evidence Table
The evidence table can be viewed here.
References
- Waller, M. (2008) Paediatric stoma care nursing in the UK and Ireland. British Journal of Nursing. 17(17); pp S25 – S29.
- Birch, J and Sica, J. (2007) One-and two-piece colostomy appliances: merits and indications. British Journal of Nursing. 16(17); pp 1042 – 1047.
- Kargl, S, Wagner, O and Pumberger, W. (2017) Ileostomy Complications in Infants less than 1500 grams – Frequent but Manageable. Journal of Neonatal Surgery. 6(1); 4.
- Ngyen, H and Houska Lund, C. (2007) Exploratory Laparotomy or Peritoneal Drain? Management of Bowel Perforation in the Neonatal Intensive Care Unit. Journal of Perinatology and neonatal Nursing. 21(1); pp 50 – 60.
- Mansout, F, Peterson, D, De Coppi, P and Eaton, S. (2014) Effect of sodium deficiency on growth of surgical infants: a retrospective observational study. Pediatric Surgery International. 30; 1279 – 1284.
- Butterworth, S, Lalari, V and Dheensaw, K. (2014) Evaluation of sodium deficit in infants undergoing intestinal surgery. Journal of Pediatric Surgery. 49(5); pp 736 – 740. Stoma Care. Great Ormond Street Hospital. Accessed via HYPERLINK "http://www.gosh.nhs.uk/health-professional/clinical-guidelines/stoma-care" http://www.gosh.nhs.uk/health-professional/clinical-guidelines/stoma-care.
- Yadav, P, Choudhury, S, Kumar Grover, J, Gupta, A, Chadha, R and Sigalet, D. (2013) Early feeding in pediatric patients following stoma closure in a resource limited environment. Journal of Pediatric Surgery. 48; pp 977 – 982.
- Rogers, V. (2003) Managing Premmie Stomas: More than Just the Pouch. Journal of Wound and Ostomy Care. 30 (2); pp 100 – 110.
- Ratliff, C, Scarano, K and Donovan, A. (2005) Descriptive Study of Peri-stomal Complications. Journal of Wound and Ostomy Nursing. 32(1); pp 33 - 37. Kent, D. (2008) Changing an Ostomy. Nursing. December. Accessed via HYPERLINK "http://www.nursing2008.com" www.nursing2008.com.
- Hyland, J. (2002) The Basics of Ostomies. Gastroenterology Nursing. 25(6); pp 241 – 244. Chandler, P. (2015) Preventing and treating peristomal skin conditions in stoma patients. British Journal of Community Nursing. 20(8); pp 386 – 388.
- Rhee, D, Karim, O, Weir, B, Stewart, D, Lukish, J, Lau, H, Abdullah, F, Gauda, E and Pryor, H. (2016) Mucous fistula refeeding parenteral nutrition exposure in postsurgical premature neonates. Journal of Pediatric Surgery. 51(11); pp 1759 – 1765. Covenant Health Enterostomy Refeeding Guideline. Accessed at extcontent.covenanthealth.ca/Policy/Enterostomy_Refeeding.pdf
Please remember to read the disclaimer
The development of this clinical guideline was coordinated by Jessica Smith, Clinical Nurse Educator, Butterfly Ward. Approved by the Clinical Effectiveness Committee. First published November 2018.