Stoma Therapy

Question 1

Ostomy Care and patient well-being

Answer 1

• Patients are typically encouraged to be as independent as possible in ostomy care from the time of their surgery
• As function declines, pouching systems and accessories may need to be simplified
• Caregivers may need to be trained and involved

Question 2

Peristomal plane - definition

Answer 2

The area under the solid skin barrier and tape of the pouching system, extending out approximately 4 inches from the base of the stoma

Question 3

Palliative Ostomy surgery

Answer 3

• Necessary by a serious complication affecting the intestine or colon
• Intended to decompress bowel obstruction or divert intraluminal contents proximal to a perforation or fistula

Question 4

Indications for palliative ostomy surgery

Answer 4

Decompression
- Bowel obstruction (e.g. by tumour)

Proximal diversion of intestinal contents

• Intestinal perforation
• Rectovaginal fistula
• Rectovesical fistual
• Rectocutaneous fistula

Often due to cancer or disease modifiying therapy (e.g. pelvic rads)

Question 5

Ways to maintain independence in ostomy care

Answer 5

Simplify care:

• Drainable punches with Velcro closure or clips
• Pouches with pre-cut or mouldable skin barriers
• Closed-end disposable pounches
• One-piece pouching systems
• Two-piece pouching systems with adhesive systems rather than flanges (less manual dexterity/strength required)

Question 6

How to manage caregiver needing to take over ostomy care

Answer 6

• Planning for this transition should be discussed with the patient
• Caregiver taking responsibility should be the person preferred by the patient and capable to learn
• Education should start early
• Consider ways to simplify care (e.g. closed end disposable drainable pouches or urostomy pouches that attach to the bedside)

Question 7

Risks to peristomal health

Answer 7

• Leakage can damage peristomal skin integrity
• Weight loss or gain may change the peristomal plane
• Ascites, varicosities related to portal HTN, tumour growth, may cause change in contour of abdominal wall
• Ensure there is expert assessment of the peristomal plane in all positions to ensure that there is a good seal with the pouching system

Question 8

Basic principles of pouching an ostomy (skin barriers)

Answer 8

1. Skin barrier to protect the peristomal skin from effluent and pouch to contain the effluent
2. Stoma opening in the skin barrier should be the same size/shape as the stoma and ranging from equal in size to no greater than 0.3cm larger than stoma size
3. Skin barrier type should be chosen based on type of effluent (e.g. liquid feces, formed stool, urinary diversions)

Question 9

When to choose firm pouching system

Answer 9

Firm cannot bend/mould to the peristomal area, useful for soft or flabby peristomal skin.

Question 10

When to choose flexible pouching system

Answer 10

Flexible systems (adhesive and no flange), useful if the peristomal plane is round, firm, or protrudes (e.g. due to hernia or ascites)

Question 11

When to use convex skin barriers

Answer 11

Convex skin barriers can be used to improve seals when stomas have retracted below skin level, or can be used when convexity is needed to fill scarring, folds, or creases, or with a stoma that is flush or retracted.

Avoid in the presence of mucutaneous separation as they may increase the separation.

Question 12

Managing unevenness in the peristomal area

Answer 12

• Use barrier pastes or washers to fill in defects and uneven areas

Question 13

How to assess the skin barrier during changes

Answer 13

Assess for any ‘hidden leaks’ - when effluent is on the skin barrier wafer, but is not extending from the adhesive

Allows establishment of the wear time of the pouching system and assess if any changes are needed to obtain a good seal

Question 14

Risk of stoma and peristomal complications

Answer 14

• Risk higher in patients with advanced disease and newly created stomas are at higher risk of mucucutaneous separation or retraction
• Long term complications include caput medusa, hernia, or prolapse which can result in leaking and irritant dermatitis or candidiasis
• Areas previously subjected to radiation makes stoma construction more difficult

Question 15

Management of stoma retraction

Answer 15

• Stoma is pulled below the skin level
• Pouching options and adjustments to obtain a good seal can help
• Convexity, support belts, binders

Question 16

Definition and Management of mucocutaneous separation

Answer 16

• Detachment of the stoma from the peristomal skin (partial or circumferential, superficial or deep)
• Often precedes retraction

Rx: Conservative management to support wound healing.

• Separation filled with dressing (either to maintain a moist environment or absorb drainage)
• Place skin barrier of the pouching system over the filled area to protect from the effluent.
• Monitor after healing for stenosis and retraction.

If separation occurs below the level of the fascia, surgery needs to be involved.

Question 17

Definition and Management of Peristomal Hernia

Answer 17

• Bulges around the stoma as a result of loops of bowel protruding through the fascial defect and into the subcutaneous tissue (may result from elevated intra abdominal pressure)

Rx:

• Ensure pouching system is a flexible system that can mould to the shape of the peristomal plane
• Hernia support belts may increase comfort and offer cosmetic benefits
• Avoid and stop irrigating a colostomy, instead use bulk laxatives and stool softeners to assist with bowel regularity.

Question 18

Stoma prolapse (definition and management)

Answer 18

• Telescoping of the bowel through the abdominal stoma site, may be due to increased intra abdominal pressure (ascites, tumour, etc.)
• Associated with stomal mucosa edema and may be at risk for trauma if a rigid pouching system is used.

Rx:

• Use a flexible, flangeless pouching system that can accomodate the stoma without trauma
• Reduce the prolapse by lying down, applying a cold back to the pouch over the stoma to reduce edema, then apply light pressure
• Patient can wear a binder made to include a prolapse flap to keep the stoma reduced during normal ADLs

Watch for severe pain - incarceration and ischemia can occur, necessitating surgery

Question 19

Caput medusa (definition and management)

Answer 19

• In patients with advanced liver disease, may develop dilatation of the cutaneous veins around the stoma
• Large peristomal varices, portosystemic collateral veins related to portal hypertension
• Means that any stomal trauma may result in profuse bleeding into the pouch itself or at the time of pouch change.

Management:

• Control bleeding if it occurs (direct pressure, cold cloth, topical hemostatic agents like silver nitrate or thrombin, suture ligation).
• Prevent bleeding (gentle appliance care, avoidance of firm, rigid, or convex pouching systems)
• In severe cases, may use sclerotherapy or surgical ligation of the portosystemic channels.

Question 20

Irritant dermatitis (definition and management)

Answer 20

• Caused by exposure to stool or urine of peristomal skin under the skin barrier
• Presents as erythema or a macular rash that progresses to moist, shallow, peristomal denudement and erosions
• May result in pain, itching, or burning

Management:

• Correct the cause (proper measurement/selection of pouching system)
• Treat the skin with a barrier powder which is then covered in liquid barrier film with each pouching system change until it heals (‘crusting technique’)

Question 21

Candidiasis (definition and management)

Answer 21

• Caused by proliferation of C. albicans in the warm, moist, dry environment beneath the skin barrier.
• Increased risk with antbiotics, cancer, chemo, immunosuppression
• Primary lesion is a pustule on an erythematous base that then evolves in the conventional candideal rash of sharply demarcated, eroded patches with small peripheral satellite papules and marginal scaling
• May result in pain, burning, itching, and leakage.

Management:

• Topical antifungals (miconazole or nystatin)
• Apply liquid barrier film over an antifungal powder for two weeks
• If other sites involved (e.g. inguinal area), start systemic antifungal with fluconazole

Question 22

Continent diversions (management)

Answer 22

• Some patients may benefit from survival techniques that allow for continent fecal and urinary diversions
• Managed by the intubation of the pouch or reservoir created during the surgery

If patient loses the ability to intubate the pouch/reservoir themselves, a caregiver may need to. Alternatively, can insert a catheter into the reservoir and attach to bedside drainage.

Urinary reservoirs - intubated q4h during the day, once at night. May need to be irrigated 1-2x daily with water due to mucous production
Fecal reservoirs - intubated QID and before bed. May need to be irrigated to thin out stool.

In case of leaking, can use a pouch system.

Question 23

Management of GI symptoms in patients with stomas

Answer 23

• Must ensure understanding of type of ostomy and how much bowel was bypassed/removed in surgery.

Ileostomy/right sided colostomy - faster transit times, avoid SR or enteric-coated meds

Fecal stoma - may experience constipation/diarrhea, be mindful of the need for laxatives when starting opioids. If severe constipation is suspected, may digitally assess with a lubricated, gloved finger.

Question 24

How to manage an impacted colostomy

Answer 24

• Oil retention fleet enema through a stoma cone followed by colostomy irrigation

Question 25

Management of diarrhea in ostomy

Answer 25

• Ensure C diff, medications, fecal impact, etc. is not the culprit
• May recommend foods to thicken the stool (bananas, rice, pastas, creamy PB, marshmallows)