Rehabilitation of the patient with a stoma or complicated wound is the responsibility of the entire health care team, and thus it is important that all members understand the principles and techniques of ostomy and wound management. As Dr. Rupert B. Turnbull, Jr., discovered in the 1950s, collaboration between the surgeon, the floor and clinic nurse, and the wound, ostomy, and continence nurse (previously known as the enterostomal therapy nurse) can facilitate this goal.
Preoperative Preparation
When an ostomy is a planned procedure, the opportunity exists for preoperative counseling and education that ideally involves the patient and his or her family, and stoma-site marking can be performed. However, every bowel surgery carries a risk of involving a stoma, even if it is extremely unlikely. This eventuality should be discussed preoperatively so that if it happens, the patient is not completely taken aback. In cases of an unexpected stoma, all the counseling and education takes place postoperatively.
Preoperative Counseling
Successful rehabilitation begins with the initial interaction with the patient. The patient and family must have a thorough understanding of the surgical procedure and likely changes to lifestyle it will cause. The alterations in anatomy and bowel and bladder function, the need for pouching, and the impact of a stoma on activities of daily living should be discussed.
Stoma Site Marking
Regardless of whether a stoma is to be temporary or permanent, stoma site marking is a key to optimizing the patient’s experience. A poorly sited and constructed stoma can be a nightmare for the patient, causing frequent leakage with skin erosion and pain, pouching difficulties, and social isolation. The best sites are usually located in the right or left lower quadrants, in the middle of rectus abdominus, away from any scars, creases, or dimples, and on the apex of the natural roll of the abdominal wall. The likely site should be checked with the patient supine, sitting, standing, and bending. The site should be visible to the patient when he or she is sitting. Some patients with pendulous abdomens or those who require constant use of a wheelchair may require a site in the upper quadrant. The procedure for selecting and marking the stoma site is provided in Box 91-1 .
- 1.
Gather equipment
- 2.
Explain procedure to patient
- 3.
Wash hands
- 4.
Apply nonsterile gloves
- 5.
With the patient supine, locate the borders of the rectus abdominus muscle
- A.
Ask the patient to lift his or her head from the bed (i.e., perform a modified sit-up), cough, or laugh
- B.
Palpate the abdomen to identify the borders of the rectus muscle
- A.
- 6.
With the patient in the supine position, locate a possible stoma site in the following manner:
- A.
Place a stoma-marking disk on the abdomen within the anatomically appropriate quadrant for the type of stoma
- B.
Position a stoma-marking disk on an area of smooth skin surface within the quadrant, avoiding the umbilicus, bony prominences (e.g., the iliac crest, symphysis pubis), creases/folds, wrinkles, scars, the belt line, and areas of previous radiation treatment
- C.
Using a water-soluble pen, mark the possible stoma site with an “x” or circle in the center opening of the marking disk
- A.
- 7.
Use a marking disk as needed to assess the initial stoma site with the patient sitting, standing, and bending; relocate the site if necessary to avoid creases, wrinkles, and irregular contours that become apparent with change of patient’s position; mark the relocated site with a water-soluble pen
- 8.
With the patient sitting and standing, determine that the site is located on the summit (apex) of the infraumbilical fat mound
- 9.
Assess the patient’s ability to see and reach the stoma site by asking the patient to touch the stoma site while in the sitting and standing positions
- 10.
With the patient in the supine position, tattoo or indelibly mark the selected stoma site
- A.
Tattoo Method
- a.
Cleanse the site with alcohol and allow to dry
- b.
Drop a small amount of India ink on the site
- c.
Using a sterile 25-gauge needle, puncture the skin three times through a drop of ink
- d.
Spread the skin
- e.
Cleanse residual ink from the skin with dry gauze followed by an alcohol wipe
- f.
If necessary, circle the tattoo with indelible ink with a contrasting color
- g.
Apply a small adhesive bandage as needed
- a.
- B.
Indelible Marker Method
- a.
Using an indelible pen, mark the preferred stoma site with an “x” or circle
- b.
Cover the mark with a transparent film dressing
- a.
- A.
- 11.
Remove gloves
- 12.
Wipe the pen and marking disk with alcohol wipes
- 13.
Discard waste in the appropriate container
- 14.
Wash hands
- 15.
Document the procedure in the electronic medical record
Preoperative stoma site selection for the patient undergoing an ileal pouch–anal anastomosis needs to take into account the mesenteric tension created by the anastomosis, which often forces the segment of ileum used for the stoma to be relatively proximal, especially in obese persons. Stomas made under these conditions have high output that is difficult to control. It is essential that such ileostomies have a good spout to prevent undermining of the skin protection by the watery stool. It is a good idea to mark two sites, one in the upper and one in the lower abdomen, so that any eventuality is covered.
Stoma marking for patients undergoing a continent ileostomy may be lower on the abdomen, and adjacent scars and folds are less of an issue, because the stoma is flush and continent. The site must still be visible to a standing or sitting patient so that the drainage catheter can be inserted.
Postoperative Management
An ideal ileostomy is matured primarily and budded; a colostomy can be flush, but a small eversion of a centimeter makes pouching easier. A flush, retracted, or excessively elongated stoma can pose pouching difficulties. A clear pouch with a skin barrier should be applied in the operating room to permit the stoma to be adequately assessed postoperatively. The aperture in the adhesive skin barrier should be approximately 1/8-inch larger than the base of the stoma. The skin should be cleansed with nonlotion soap and dried prior to pouch application. The procedure for the application of a one-piece pouch is included in Table 91-1 . If a rod is present, a flat flexible pouching system should be fitted over, not under, the rod, and the pouch should be labeled “rod underneath” to prevent accidental dislodgement and mucosal trauma.
| How to Change a Disposable One-Piece, Cut-to-Fit Pouch with an Attached Skin Barrier | How to Change a Disposable Two-Piece Pouch with a Cut-to-Fit Skin Barrier Flange |
|---|---|
|
|
The pouch should be changed on the first postoperative day after conventional open surgery, with rod removal from day 3 to 5, depending on tension. For laparoscopic stomas, if the pouching system is adhering well, a pouch change is performed on postoperative day 2, when the rod is removed, depending on the tension. With each pouch change, the stoma, mucocutaneous junction, and peristomal skin are assessed. Postoperative stoma and peristomal skin complications and their management are described in Tables 91-2 and 91-3 . Stomas that are retracted or flush, as well as patients with a soft abdomen, may benefit from a convex pouching system. Principles of fitting are highlighted in Table 91-4 .
| Problem | Characteristics | Interventions |
|---|---|---|
| Mucocutaneous separation | Separation of the suture line at the junction of stomal mucosa and skin Erythema around the area of separation; may have drainage or pain at site Can be partial or circumferential; shallow or deep | Assess depth of separation: if peritoneal contamination is a concern, resuture stoma to skin Shallow separation: use skin barrier powder to fill the defect, and pouch Deep separation: gentle packing with gauze may be necessary; cover with thin hydrocolloid or other appropriate dressing, and pouch If infection is a concern, use an antimicrobial dressing and antibiotics as needed If a large volume of fluid is draining from the separation, include the area in the pouch opening |
| Necrosis | Mucosal color dark red, maroon, purple, gray, brown, or black; stoma is dry, hard, or flaccid | Use a clear pouch in the postoperative period to allow for ongoing mucosal assessment Assess depth of necrosis If below the fascial level, perform a repeat operation with reconstruction of the stoma For superficial necrosis, provide conservative management with the tissue allowed to slough with debridement as needed |
| Parastomal abscess or fistula | Abscess adjacent to stoma Fistula may be present | Administer systemic antibiotics Perform incision and drainage of the abscess site, which is best done with a mushroom-tipped catheter Perform contrast studies to define the extent of the fistula Perform surgical intervention as needed Modify the pouching system based on the location and extent of the fistula or abscess |
| Food bolus obstruction | Severe, crampy abdominal pain with nausea, vomiting Output may cease or become watery and odorous Stomal edema is common Patient relates recent history of ingesting high-fiber foods such as peanuts, popcorn, or string vegetables | Conservative management: warm bath, peristomal massage, and liquids Supportive measures: intravenous fluid replacement, pain medications, and nasogastric tube Ileal lavage |
| Hernia | Hernia around stoma presents as a bulge that can interfere with pouch seal, causing mechanical or irritant contact dermatitis | Use of support belt Perform pouch modification to accommodate change in contour Consider discontinuing routine colostomy irrigation Surgical repair plus or minus relocation |
| Prolapse | Telescoping of the bowel through the stoma; length and diameter of mucosa increases with potential for laceration | Conservative: Manually reduce prolapse; apply binder with prolapse overbelt while the person is supine; reassess pouching system for proper aperture size Surgical management |
| Retraction | Stoma recedes below skin level, causing a variety of pouching and peristomal skin difficulties If a loop stoma recedes, it will not divert completely | Assess for recurrent disease such as Crohn disease Refit pouching system often by increasing degree of convexity Perform surgical revision if pouching modification is not successful |
| Stenosis | Narrowing of the lumen of the stoma, which can lead to partial stomal obstruction | Preventive measures such as an appropriate pouching system, prompt treatment of pseudoverrucous lesions; avoid routine dilation of stoma Stool softeners and laxatives as needed Surgical revision |
| Trauma | Laceration or bruising of mucosa Lacerations are seen as yellow to white linear marks in the mucosa | Identify and eliminate causative factor for the trauma, e.g., correct aperture, clothing alterations Use measures to control bleeding as needed |
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