Stoma Care oxford

Question 1

Principles of ostomy care

Answer 1

• independence encouraged
• deline of function - pouching systems simplified
• Caregivers may need to be involved. Preferably one that patient chooses

Question 2

Definition of peristomal plane

Answer 2

• Area under solid skin barrier and tape of pouching system
• extending out 4 inches from base of stoma

Question 3

Palliative Ostomy Surgery - indications

Answer 3

• decompression of bowel obstruction
• diversion
• proximal to perforation, obstruction, rectovaginal, rectovesicular, enterocutaneous fistula
• pelvic radiation

Question 4

How can one maintain independence in ostomy care?

Answer 4

• drainable pouches with velcro, clips
• pre cut, moldable skin barriers
• closed ended disposable pouches
• one piece systems
• two piece systems with adhesives instead of flanges

Question 5

How to help caregiver who needs to take over ostomy care?

Answer 5

• plan with patient
• person should be preferred by patient, and capable to learn
• early education
• consider simplified care

Question 6

Risks to peristomal health

Answer 6

• leakage can damage skin
• weight loss
• ascites
• varicosities
• tumour growth

Question 7

Basic principles of pouching in ostomy (Skin barriers)

Answer 7

• Skin barrier to protect peristomal skin from effluent
• Pouch to contain effluent
• Stoma opening in skin barrier should be same size and shape of stoma (no greater than 0.3cm larger than stoma)
• skin barrier type chosen on type of effluent (liquid feces, formed stool, urine)

Question 8

When to choose firm pouching system

Answer 8

• useful for soft or flabby peristomal skin

Question 9

When to choose flexible pouching system

Answer 9

• adhesive, no flange
• useful if peristomal plane is round, firm, or protrudes

Question 10

When to use convex skin barriers / pouching system

Answer 10

• Convex skin barriers improve seals when stomas have retracted below skin level.
• Fill scarring, folds, creases
• retracted or flsuh stoma
• Avoid if mucocutaneous separation - may worsen

Question 11

Managing uneven peristomal area

Answer 11

• use barrier pastes
• fill in defects and uneven areas

Question 12

How to assess skin barrier during changes

Answer 12

• Assess for hidden leaks
• Effluent on skin barrier
  *

Question 13

Risk of stoma and peristomal complications

Answer 13

• advanced disease
• newly created stomas
• high risk of mucocutaneous separation or retraction
• caput medusa (varicosities peristomal secondary to portal hypertension)
• hernia
• prolapse
• irritant dermatitis
• candidiasis
• prior radiation

Question 14

Management of stomal retraction

Answer 14

• stoma is pulled below skin level
• pouching options and adjustments for a good seal help
• convexity, supprt belts, binders

Question 15

Definition and management of mucocutaneous separation

Answer 15

• detachment of stoma from peristomal skin (partial or circumferential, superficial or deep)
• precedes retraction
• conservative mx
• separation filled with dressing
• skin barrier over filled area to protect it
• monitor for stenosis and retraction
• surgery if separated below fascia

Question 16

Definition and management of peristomal hernia

Answer 16

• bulges around stoma
• loops of bowel through fascia into subcut tissue
• elevated intraabdominal pressure
• Rx:
  
  • flexible pouching
  • hernia support belts
  • stop irrigating colostomy
  • laxatives, stool softeners

Question 17

Definition and managment of stoma prolapse

Answer 17

• telescoping of bowel though stoma
• mucosal edema
• risk of trauma
• intraabdominal pressure, ascites, tumour
• watch for incarceration
• Rx:
  
  • flexible, flangless pouch
  • reduce prolapse by lying down, ice, pressure
  • wear a binder with prolpase flap
    *

Question 18

Definition and management of caput medusa

Answer 18

• liver disease
• portal hypertension
• varicosities of cutaneous veins around stoma
• stomal trauma risk of bleeding
• Rx:
  
  • control bleeding
  • gentle appliance care
  • avoid firm, rigid, convex pouching systems
  • scleoptherapy, surgical ligation

Question 19

Definition and management of irritant dermatitis

Answer 19

• stool urine exposure to peristomal skin
• erythema, macular rasj
• moist, shallow, denuded skin
• pain, itching burning
• Rx:
  
  • correct pouching system
  • barrier powder
  • liquid skin barrier until it heals

Question 20

Definition and management Candidiasis

Answer 20

• C albicans
• antibiotics, cancer, chemo, immunosuppression
• pustule on erythematous base, dermarcated patches, peripheral satellite lesions
• pain, burning, itch
• Rx:
  
  • miconazole, ketoconazole, nystatin
  • liquid barrier film over antifungal powder x 2 weeks
  • If multisite - systemic antifungal

Question 21

Continent diversions

Answer 21

• intubation of resevoir
• caregiver can intubate
• catheter into resevoir into bedside drainage
• urinary resevoirs q4h in day, once/night
• fecal resevoirs intubated qid and before bed
• ppouch system if leaking

Question 22

Management of GI sx in patients with stomas

Answer 22

• must know how much bowel removed
• type of ostomy
• Ileostomy / R sided colostomy - fast transit, no SR, enteric coated meds
• Fecal stoma : constipation or diarrhea. laxatives, digital disimpaction

Question 23

Impacted colostomy

Answer 23

• Oil retention fleet enema through stoma
• colostomy irrigation

Question 24

Ostomy diarrhea management

Answer 24

• C diff
• medications
• fecal impaction
• foods : bananas, rice, pasta, PB, marshmallows