1. Stoma Care Nurse Specialist Gateshead Health NHS Foundation Trust
GP Update on Stoma Care
Heather Wilson
Stoma Care Nurse Specialist
Gateshead Health NHS Foundation Trust
Handouts available for this talk

2. Aims of the Session
To give a brief overview of stoma care management and the support of the patient/family/carer
Discuss the role of the Stoma Care Nurse Specialist
To discuss a variety of stoma problems that patients may face
To outline the management of these problems

4. History
First surgical stomas were created on battle casualties in the early in the early 1700s
No documentation of the specific care of stoma patients in the nursing profession press until the late 1930s (Plumley,1939)
The first stoma therapist was not a nurse , but a patient. Norma Gill, Ohio,USA
In the UK Barbara Saunders a ward sister, set up the first stoma clinic in 1969.
1971 saw the first stoma care nursing posts

5. Types of Stomas Over 80,000 people in the UK living with a stoma
Stoma greek word for mouth
Colostomy (wet colostomy)
Ileostomy
Urostomy
Loop or end, permanent or temporary

6. End Colostomy

7. End Ileostomy

8. Loop Ileostomy

9. Reasons for needing a stoma
Varied
Cancer – bowel/rectum or bladder
Inflammatory Bowel Disease – Crohn’s Ulcerative Colitis
Diverticular Disease
Congenital abnormalities
Bowel ischaemia
Irradiation damage, fistula formation

10. Stoma Care Nurse Specialist
Some are Colorectal Nurse Specialists
Present in all major hospitals in the NE
Some are community based
Strong network, regional meetings, patient open days, study events, collaborative working/patient referrals
Sub specialist nurses in Paediatrics and Urology

11. Senior Nurse who has undertaken formal training/examination in the field of stoma care/colorectal
Clinical and consultative role
Patient advocate, support and education
Teaching
Management, research, audit, change agent

12. Stoma Care Management
Team approach – specialist nurses, ward and community nurses, medical staff, patient, carers and family
Practical Support – how to look after the stoma and surrounding skin, dietary advice, types of appliances, holiday advice
Psychological Support – emotional reaction to this type of surgery, lifestyle issues, sexuality and body image
Preoperative preparation including siting
Post operative support and education
Continued support once patient is discharged into the community
Aim is for the patient to become an‘expert’ in stoma management and adapts to life with a stoma

13. Stoma Problems Divided into 3 main areas
Problems in the management of a stoma e.g. hernia, prolapse, stenosis
Skin conditions which may arise due to the stoma or wearing of an appliance
Psychological issues

14. Post op stoma shrinkage
6 to 8 weeks for stoma to shrink in diameter and spout. Patients may need to change appliance type e.g. Convex
Need regular review by stoma nurse in the first 2 to 3 months.

15. Colostomy Effluent less corrosive to the skin
Usual formed stool, closed pouch, 3x daily
Transverse colostomy may need drainable
Some patients may opt for irrigation
Constipation –diet, fluids, drugs, age, mechanical e.g. Hernia, stricture, adhesions
Oral laxatives/microlax enemas/suppositories

16. Diarrhoea – right sided/transverse stomas
Chemotherapy/radiotherapy
Infection – stool sample
Drugs, diet, stress, malabsorption, disease e.g.crohn’s, cancer, sub acute obstruction
Imodium

17. Ileostomy Effluent very corrosive to skin. 1-2 days.
Output should be “porridgy”, mls per day. Imodium.
Increased/fluidy output –infection, diet, drugs
Obstruction- foods high in cellulose, adhesions, strangulated hernia, stenosis
Stoma oedematous, cramps, fluid effluent then ceases
Imodium
High output stoma litres, TPN, electrolye replacement

18. Loop ileostomy can be difficult to manage due to its odd shape, mucus from distal part
High output ileostomy – electrolyte drinks, TPN, appliance type
Chemotherapy treatment- increasing stoma activity, skin more sensitive, reduced feeling in patient’s fingers

19. Urostomy
Infection – clean specimen using a fine catheter, or place collecting bottle under clean stoma. Mucus shreds in the urine is normal
PH of the urine should be kept between 5 and 7. Ascorbic acid 100mg, cranberry juice
Phosphate deposits, Chronic papillomatous dermatitis around urostomies. 50% household vinegar soaks, appliance review.

20. Necrosis / Sloughy Stoma
Early post op complication, too tight appliance
Compromised blood supply
Difficult surgery
Post op stoma bridge
Ill fitting appliance
If superficial will slough off
Use intrasite gel or orabase paste to aid removal of slough
Refer to surgeon in severe cases

21. Necrosis and Dehiscence
This picture shows a necrotic stoma which has dehisced from the skin.
Treated by applying intrasite gel or orobase paste, covering with stomahesive paste or GX seal and appliance.
Severe dehissance may need suturing.

22. Stenosis Narrowing of the lumen of stomal outlet
Healing of necrotic tissue, dehiscence of stoma, poor surgical technique
Secure appliance
Patient may be taught to dilate
Surgical revision
Patients may need convexity type appliance to protect skin or the use of barrier protection sprays and pastes.
These two pictures show stenosed stoma.
The following picture is after reconstruction of the stoma.

23. Retraction Bowel under tension Surgical technique, post op weight gain
Can be difficult to manage –skin damage/leaks/difficult for patient to see stoma. Appliance review.
Convex products, rings, pastes, belt
May need to change pouch more frequently
Surgery may be indicated

24. Parastomal Hernia Affects 40% plus an increasing problem
More common in older patients
Loss of muscle tone
Appliance review
Support garment
Observe patient
Surgery
This is a common condition.
Affect the patients lifestyle, clothing, confidence and self-esteem.
Problems with appliances adhering to the skin, leaks and sore skin.
Patients may need to change type of appliance - larger appliance with wider flange or oval shaped appliance, use a belt or support garment.
Not all patients need surgical intervention- if surgery is contraindicated or hernia not causing any problems.

25. Prolapse
Defined as when a length of bowel prolapses out onto the exterior of the abdominal wall
More common in transverse loop colostomies (larger stoma)
Fit larger appliance
Reduce prolapse
Surgical intervention
Can be distressing for patient and family. Need reassurance, explanation and support.
Severe prolapse will need assessment by surgeon.
Risk of damage to the bowel tissue and necrosis.
Some patients may not need surgical management and can be managed with larger type appliance, to contain stoma and effluent.

26. Pancaking
Colostomy effluent does not fall to the bottom of the pouch, collects around the stoma. Can be difficult to manage.
Leaks, frequent pouch changes
Sore skin
Odour issues – blocked filter
Cover filter, tissue paper in pouch, lubricating gel, diet, 2 piece pouch

27. Trauma to Stoma Many causes Most common ill fitting appliance
Cause laceration on stoma. Bleeding.
Usually heals quickly
Use of special powders e.g. orahesive, hollister
May need suturing
Other causes of trauma
Self-harm- needs careful assessment
Major bodily trauma e.g. RTA
patients can fit adaptations to seat belt to
limit damage to stoma.
Contact during sports activities - can use protective stoma shields.

28. Over Granulation Occurs at the junction between stoma and skin
Can occur at any time
Probably a reaction to irritation
Bleeding
Soreness
Powders
Silver nitrate
Liquid nitrogen
Need to check size of appliance aperture which may be rubbing on the stoma and causing overgrannulation.
If patients are having no symptoms just observe.

29. Skin Problems (1) Very common 1/3 of people with colostomies
2/3 ileostomy or urostomy pts experience skin problems Lyon & Smith, (2001)
Many causes - poor fitting appliance, flush stoma, poorly sited stoma, hernia, weight gain, pre-existing skin condition e.g. eczema
These two pictures show quite a flush ileostomy.
Spout pointing downwards, effluent which is very corrosive to the skin is leaking under the bag and lifting it from the skin.
Result very sore, inflammed skin which can prevent further appliances from adhering.
This patient needed a convexity type product where the flange is domed shaped providing extra protection around the base of the stoma and pushing the stoma further out.
This reduces the chance of stomal effluent collecting around the stoma a leaking under the bag.
Some patients may need the size of appliance aperture reducing so that it fits snugly around the stoma.

30. Skin Problems (2) Allergic reaction Allergic contact dermatitis
Patch test. Change pouch type.
? Refer to dermatologist
May need topical steroid . Lotion, inhalers, nasal spray
Most stoma appliances are designed to be kind to the skin.
Some patients can get an allergic reaction as demonstrated in this picture. Treated by changing appliance type/manufacturer.
Patients may get a reaction to the plastic - use of cotton covers.
Severe reactions may need patch test - refering to a dermatologist.
Application of alcohol-based lotions do not interfere with appliance adhesion e,g treatment of psorasis.

31. Check stoma spout, abdomen examination
Check stoma effluent
Appliance review
May need barrier spray, wipes or powder to heal skin
Use of accessories e.g. Rings/paste , skin creases, dips

32. Patient Impact Stoma formation and stoma complications can
effect the physical, psychological, sexuality and social well being of the patient
Loss of self-esteem
Change in body image
Loss of confidence
Social recluse
Affecting work, relationships, social activities / holidays
Regular support especially early in recovery period is vital
Early assessment of any stomal complication cannot be overestimated.
Patients need constant information, reassurance and support.
As highlighted the impact of such complications can be dramatic not only for the patient but also for the family as well.

33. Patient Support Healthcare Professionals Clinical psychology
National and local patient support groups e.g. Urostomy association
One to one patient support
Stoma appliance manufacturers, pharmacy, dispensing appliance contractors

34. Conclusion Stomal problems should be assessed holistically
Using multi-disciplinary team
No one simple answer to any of the complications
Patients need easy access to specialist nurse for ongoing advice and support
Nurses need to involve other specialists where appropriate e.g. tissue viability nurse, dietitian
Dealing promptly and affectively with a problem will minimise patient anxiety and promote adaptation.

35. Conclusion
Stoma care management can be varied, challenging and at times complex.
Careful assessment, prompt management and good communication within the team is essential, as is ongoing patient support.
The reward is a confident patient who is able to just get on with life.
Thank You for listening.
There are handouts at the front
Enjoy your lunch.

36. Thank you for listening
Any questions ?