965_Stoma Care Guidelines 2009

STOMA CARE GUIDELINESGUIDELINES FOR NURSES CARING FOR PATIENTS WITH A STOMA

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CONTENTS

1. WHAT IS A STOMA?.............................................................................................................................................4

2. SOME REASONS WHY PATIENTS MAY NEED A STOMA..........................................................................4

3. COLOSTOMY..........................................................................................................................................................4

4. ILEOSTOMY...........................................................................................................................................................4

5. UROSTOMY............................................................................................................................................................4

6. AIM OF THE STOMA CARE SERVICE AT THE ROYAL FREE HOSPITAL...........................................4

7. ROLE OF WARD NURSES....................................................................................................................................4

8. WHO MAY ASSIST?..............................................................................................................................................4

9. IMMEDIATE POST-OPERATIVE OBSERVATION........................................................................................4

10. EQUIPMENT NEEDED.....................................................................................................................................4

11. EMPTYING A DRAINABLE POUCH.............................................................................................................4

12. CHANGING A ONE-PIECE CLOSED / DRAINABLE POUCH..................................................................4

13. DISCHARGE.......................................................................................................................................................4

14. APPLIANCES......................................................................................................................................................4

14.1 COLOSTOMY APPLIANCES.................................................................................................................................414.2 ILEOSTOMY APPLIANCES...................................................................................................................................414.3 UROSTOMY APPLIANCES...................................................................................................................................414.4 HIGH OUTPUT STOMA.......................................................................................................................................4

15. ACCESSORIES...................................................................................................................................................4

15.1 STOMAHESIVE PASTE........................................................................................................................................415.2 COHESIVE OSTOMY SEALS................................................................................................................................415.4 ORABASE PASTE................................................................................................................................................415.5 OSTOMY CLIPS..................................................................................................................................................4

16. HOW TO MANAGE PROBLEMATIC SKIN CONDITIONS......................................................................4

16.1 EXCORIATED SKIN.............................................................................................................................................416.2 SKIN REACTION.................................................................................................................................................416.3 ITCHY SKIN.......................................................................................................................................................416.4 RED OR BROKEN SKIN......................................................................................................................................4

17. POTENTIAL PROBLEMS ASSOCIATED WITH STOMA CARE.............................................................4

17.1 AN APPLIANCE THAT IS CUT TOO SMALL, MAY CAUSE:....................................................................................417.2 AN APPLIANCE THAT IS CUT TOO LARGE, MAY CAUSE:.....................................................................................417.3 FACTORS WHICH MAY PREVENT GOOD ADHESION OF AN APPLIANCE:..............................................................4

18. THE MANAGEMENT OF ABDOMINAL FAECAL FISTULAE................................................................4

18.2 WHY ARE WOUND MANAGERS USED?..............................................................................................................418.3 WHAT EQUIPMENT DO I NEED TO APPLY A WOUND MANAGER?......................................................................418.4 HOW DO I APPLY A WOUND MANAGER?..........................................................................................................4

19. OBTAINING SPECIMENTS.............................................................................................................................4

20. SUPPORTING INFORMATION......................................................................................................................4

21. REFERENCES....................................................................................................................................................4

22. APPENDIX 1 PROTOCOL - MANAGEMENT OF HIGH OUTPUT STOMA / ENTEROCUTANEOUS FISTULA...................................................................................................................4

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VALIDATION GRID:

Title:Stoma Care GuidelinesGuidelines for nurses caring for patients with a stoma

Authors:Louise Foulds, Specialist Sister, Stoma CareAnnalyn Manalastas, Specialist Sister, Stoma Care

Target audience: Nurses caring for patients with a stoma

Commissioning Body: Clinical Practice Group

Stakeholders consulted:

Clinical Practice GroupDirectorates: Anaesthetics & Critical Care

Clinical Haematology, Oncology & Private PracticeHepatology, Nephrology & TransplantationMedicineNeurosciencesWomens’ & Children’sRNTNE, ENT, Audiology & Ophthalmology

Clinical Practice/ Advanced Practice:

Clinical practice

Associated Documents:Infection Control Guideline for Hand WashingInfection Control Guideline for Specimen Collection

Guideline Replacement: Stoma Care – April 2007

Date of Submission: April 2009

Review Date: April 2011

Key words: Stoma, Colostomy, Ileostomy, Urostomy

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AIM: To provide a level of awareness to Royal Free Hospital staff regarding the practical and psychological needs of stoma patients.

1. WHAT IS A STOMA?

The word comes from a Greek word meaning ‘mouth’ or ‘opening’.

At The Royal Free NHS Trust (RFH) we see mainly colostomies, ileostomies and urostomies.

Stomas are created for many different reasons and can be either an elective or an emergency procedure.

Stomas can be either permanent or temporary.

2. SOME REASONS WHY PATIENTS MAY NEED A STOMA

1) Crohn’s and Ulcerative Colitis (Inflammatory Bowel Disease)

2) Cancer (bowel, renal, ovarian)

3) Diverticular disease

4) Irradiation damage

5) Neurological disorders (e.g. Spina Bifida, Incontinence from neurological

damage)

6) Trauma (stab or gunshot wounds)

7) Congenital disorders (imperforate anus, bladder/bowel extophy, and Hirschsprungs disease)

8) Sphincter damage (following childbirth)

9) Fistulae

10) Pelvic abscess

11) Faecal incontinence

12) Anastomic leak

13) Volvulus

14) Strangulated hernia

15) Familial Adenoma Polyposis

16) Anal Fissure

17) Mega rectum

18) Ischaemic bowel

19) Anastomotic stricture

Stoma Care Guidelines April 2009 4

3. COLOSTOMY

An opening onto the abdominal surface created from the large bowel (colon)

An end piece of bowel may be brought out (an end or terminal colostomy) or both loops may be brought to the surface (a loop colostomy)

The stoma is usually flush with the skin and sited on the left-hand side of the abdomen, but may be in any position

The output is usually of a formed or soft consistency

A patient with a colostomy would usually wear a closed pouch

A permanent colostomy would be formed when

There is evidence of a low rectal tumour, where an attempt to join the bowel to the anus may leave the patient permanently incontinent of faeces.

For rectal cancer a wide and long excision is important in order to clear the cancer if at all possible.

In the case of an abdomino perineal excision of rectum (AP Resection), the anus is removed to obtain tumour clearance and the space closed with sutures. The colostomy in this case would be permanent.

A Hartmanns procedure involves raising a colostomy but in this instance the rectum and anus are not excised. The proximal bowel is brought out as a colostomy (on the left side) and the distal portion is oversewn and placed back inside the abdomen/pelvic cavity but it may be sewn to the lower end of the incision line (just above the symphisis pubis) and be called a Mucous Fistula.

Some temporary colostomies may be raised following trauma injuries, or when there is obstruction. For such cases a loop colostomy may be formed. (Breckmen, 2005)

4. ILEOSTOMY

An opening onto the abdominal surface created from small bowel (ileum)

An ileostomy may be brought out as an end (terminal) or loop

Since small bowel content can be corrosive and potentially harmful to the skin, the stoma ideally has a spout. This spout allows for a more secure fitting appliance and has therefore less potential for leakage

The output can be variable and range from very watery to a soft consistency

The ileostomy is usually sited on the right hand side of the abdomen but can be in any position

A patient with an ileostomy would wear a drainable pouch, with a clip or other fastening

Many ileostomies are now temporary and usually done to protect anastomotic sites (a join between two pieces of bowel following resection). (McCahon, 1999)


Patients with severe Ulcerative Colitis (UC), who do not respond to medical treatment, usually require surgery. In this operation the whole colon is removed (total colectomy) and an end ileostomy created. The rectal stump may be brought out as a mucus fistula, usually at the lower end of the wound. Removing the colon and rectum rids the patient of UC, however, the rectum is usually removed at a later date.

Some patients with Crohn’s disease (an inflammatory disorder potentially involving the whole GI tract) may require a permanent or temporary ileostomy, but equally may have a small portion of the colon removed and have a colostomy.

5. UROSTOMY

Also known as an ileal conduit.

The ureters, once removed from the bladder, are diverted to a segment of small bowel (ileum), which is then brought out onto the abdominal surface as a stoma.

A urostomy usually has a spout. This spouting allows for a more secure fitting appliance and less potential for leakage.

A urostomy is usually sited on the right hand side of the abdomen but can be in any position.

A urostomy appliance has a tap drain and an integrated non-returnable valve (built into the inside of the bag), to prevent urinary reflux.

Output is urine and mucus.

Urostomies are formed for cancer of the bladder, necessitating its removal.

It may also be necessary where there is intractable incontinence, as in childbirth injury and for neurological disorders, e.g. spina bifida. (Black, 2000)


6. AIM OF THE STOMA CARE SERVICE AT THE ROYAL FREE HOSPITAL

1) To see all patients pre-operatively, where it is possible a urinary or faecal stoma will be created, to provide pre-operative support and information including both verbal and written. To site the position of the stoma for all patients prior to surgery.

2) To teach stoma care to patients post-operatively and to promote independence and self-care.

3) To care for patients with faecal/urinary fistulae (see page 16)

4) To offer guidance, information and support to patients and their families in hospital.

5) To ensure patients are referred to the appropriate community stoma care nurse.

6) To liaise with the multi-disciplinary team about care needs of patients.

7) To educate nursing staff and students through practical teaching sessions and dissemination of information and to act as a resource.

8) To see outpatients at the request of a doctor, nurse or other health professional or the patient themselves.

7. ROLE OF WARD NURSES

1) It is the nurse’s responsibility to empty stoma appliances on a regular basis if the patient cannot do this for themselves.

2) If a patient’s appliance is leaking then it must be changed, as the contents can be corrosive to the skin. It is inappropriate to tape up leaking appliances. Leaking appliances that have been taped up will be investigated using the trust clinical incident reporting frame.

3) If the patient’s skin becomes red, excoriated or blistered, report to stoma care nurse.

4) If the patient is having any problems with leaking appliances, report to the stoma care nurse.

5) If you have a patient going to theatre for stoma formation, please contact the stoma care nurse as soon as possible so that the patient can be given adequate pre-operative support and information, EVEN IF THEY ARE LIKELY TO BE DISCHARGED AND LATER RE-ADMITTED FOR THEIR OPERATION.

6) If a patient has returned from an emergency operation, in which a stoma has been formed, inform the stoma care nurse.

7) If you have a patient with a stoma be aware of how to use products and to facilitate self-care, according to the written care plan.


8. WHO MAY ASSIST?

Staff who may assist patients with their stoma care (emptying and changing the bag)

Staff nurses, students and health care assistants who, through observation and then supervised practice, are confident to perform stoma care and accept accountability for their own actions and with the permission from the student’s mentor or the nurse-in-charge, are able to assist in these procedures.

Whilst carrying out stoma care, the patient’s dignity must be respected at all times and if there is any aspect with which the nurse feels unsure, they should seek assistance.

If the patient has a NEWLY FORMED stoma (colostomy, ileostomy, urostomy) staff must ensure that all output is measured and accurately recorded.

9. IMMEDIATE POST-OPERATIVE OBSERVATION OF A NEWLY FORMED STOMA

The appearance of the stoma should be checked regularly. This can be documented on the fluid balance chart next to stoma output measurements.

It should be a reddish/pink colour (similar to the inside of the mouth).

It can be swollen and oedematous in the early post-operative period. This may be due to bruising of the bowel during surgery.

If the stoma is black/very dark, the blood supply may be compromised. This will lead to necrosis. A member of the surgical team and stoma care nurse must be informed immediately.

Please apply ORABASE PASTE immediately to attempt oedema reduction. This is available in the stoma cupboard on 9 West.

It is very important to document all output from the stoma (e.g. wind as well as stool). If there is no output please document nil or % on the fluid balance chart

Ensure the appliance is adhering to the skin properly and that no leakage has occurred.

Check that the flange is surrounding the stoma comfortably and not sitting on top of the stomal mucosa, or cut too tightly.

For the first few days post-operatively, a clear drainable bag should be used. This ensures good visibility and early detection of any problems. After approximately three days it is normal to change to a beige coloured/opaque bag. Patient preference is important in this choice. An opaque bag is used to aid patient comfort. If there is a particular problem with the stoma a clear bag would be used. Always place the flange directly onto the skin. Any wound dressings (e.g. laparotomy wound, Robinson drains or any other incisional sites) that may be insitu can be placed on top of the appliance. The rationale for this is to prevent leaks from the stoma which may result in stool leaking onto wounds.

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10. EQUIPMENT NEEDED

EQUIPMENT NEEDED IN ORDER TO CHANGE A STOMA APPLIANCE

WARM TAP WATER

NON-STERILE WIPES

DISPOSAL BAG

NEW APPLIANCE

SCISSORS

DISPOSABLE GLOVES & APRON(Patients do not need to wear protective clothing when caring for their own stoma, except to

prevent soilage of clothing. Good hand hygiene is sufficient to prevent self-infection)

ADHESIVE REMOVER

AIR FRESHENER

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11. EMPTYING A DRAINABLE POUCH

ACTION RATIONALE

If the patient is in bed, protect clothing and bed linen.

To reduce the necessity for renewing clothing and avoid embarrassing the patient due to soiling.

Wash hands with soap and water. Put on disposable gloves and apron to protect from contents of pouch.

Prevent contamination and cross infection.

Place jug/container under the outlet of the pouch. Remove the clip and put to one side or undo velcro.

Clips should be washed to remove dried faeces, prevent odour and soiling of clothes.

Empty pouch contents into the container. Cover and set aside until the procedure is complete.

To empty the pouch.

Clean the outlet with tissue, going at least one inch inside the bag.

This helps reduce odour and soiling of the patient’s clothes.

Close bag using velcro fastener/clip To prevent spontaneous emptying of the pouch.

Dispose of soiled dressings and waste in a yellow plastic bag.

To ensure appropriate disposal of waste.

Measure the output To monitor hydration / fluid balance.

Remove gloves and apron, discarding clinical waste bag.Wash hands with soap and water.

Prevent contamination and cross infection. Ensure correct waste segregation.

Stoma Care Guidelines April 2009

APPLIANCES MUST BE DRAINED REGULARLY, WHEN IT IS 2/3RDS FULL PREVENTING LEAKAGE AND ACUTE EMBARRASSMENT TO THE PATIENT.

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12. CHANGING A ONE-PIECE CLOSED / DRAINABLE POUCH

ACTION RATIONALE

If a patient is in bed, protect their clothing and bed linen.

Reduce the necessity for renewing clothing.

Wash hands with soap and water. Put on disposable gloves and apron to protect from contents of pouch.

Prevent contamination and cross infection.

If the patient is wearing a drainable pouch, empty first to avoid spillage. Then, by starting at the top of the flange, peel slowly from top to bottom, until the flange has been removed. Use adhesive remover if necessary.

To reduce discomfort and minimise the risk of skin damage.

Wash the stoma and peristomal area with warm water and soft wipes.*Toilet tissue and Kleenex should not be used, as they disintegrate when wet.

To remove glue and debris from around the stoma.

Dry the skin with soft wipes. To remove moisture and obtain good adhesion from the flange.

Measure the stomal size and where appropriate, make a template. Stoma size will change during the first 8-10 weeks so stoma needs to be measured before changing the bag. After 10 weeks the size will remain the same and a final template can then be used.

To ensure a correct fitting pouch and maximise skin protection.

Cut the flange according to the size of the stoma.

To ensure a correct fitting pouch and maximise skin protection.

Remove the backing paper. Fold the pouch in half (so that the flange is rounded). Position the bottom edge underneath the stoma.

To ensure a secure fitting appliance.

Fold the top half of the flange over the stoma and press firmly to the skin from the edge of the stoma outwards. Ensure that the stomal mucosa is not covered with the flange.

To ensure a good seal around the stoma.

Apply gentle pressure around the flange, ensuring its adhesion to the skin. Ensure the flange is free of wrinkles and creases, which may cause leakage.

Heat from the hand and gentle pressure improves adhesion.


Apply a clip, if appropriate or roll the end up for velcro closures.

To prevent spontaneous emptying of the pouch.

Remove gloves and apron, discard into clinical waste bag. Wash hands with soap and water.

Prevent contamination and cross infection.Ensure correct waste segregation.

13. DISCHARGE

Prior to discharge, the Stoma Care Nurse will ensure:

1) The patient is competent in stomal management.

2) That patient and family members are happy with the arrangements.

3) Ensure the patient is aware of how to obtain further supplies, i.e. via the chemist or Delivery Company.

4) The patient has sufficient supplies of products to take home.

5) The patient is given contact numbers for both the Hospital and Community Stoma Care Nurses.

6) The patient is made aware of potential complications and how to address them.

7) The GP and Community Stoma Nurse are informed of the patient’s discharge.


WARD STAFF

PLEASE ENSURE THAT THE DISCHARGE DATE IS DISCUSSED

WITH THE STOMA CARE NURSE.

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14. APPLIANCES

All appliances come in either: ONE-piece (where the pouch is welded to the flange) or TWO-piece systems (where the pouch and flange can be separated)

14.1 Colostomy Appliances

If using a one-piece closed pouch, it must be renewed every time the pouch becomes full. This will involve cleaning the stoma and surrounding skin before putting the new pouch on.

In general, colostomy patients will change their pouch once or twice a day.Those using a two-piece product will renew the pouch once or twice a day, leaving the flange (base plate) in place, to be changed usually every second or third day.

14.2 Ileostomy Appliances

Ileostomies can be very active in the early stages following surgery and will need to be closely observed and the appliance emptied regularly.

Immediately post-operatively a valid and accurate fluid balance chart must be maintained as these patients can easily become dehydrated.

If using a one-piece drainable pouch then the whole appliance will need renewing every 2-3 days. The pouch itself will require emptying 4-6 times a day and possibly once overnight.

Two-piece drainable pouches need renewing approximately every 3-4 days, but will need to be emptied regularly.

14.3 Urostomy appliances

With either a one or two-piece system, the appliance would usually stay in place 2-3 days. The pouch itself (depending on oral fluid intake) would need regular emptying.

During urostomy formation, a stent is usually inserted into each ureter to ensure its patency. The stents are colour coded and drain through the stoma into the urostomy bag. The stent in the right ureter is usually red/pink in colour. The stent in the left ureter is usually blue in colour. They are left in place for approximately ten days or according to the surgeon’s preference. They must not be removed without the surgeon’s permission.

A urometer is recommended to allow hourly urine measurements in the early post-op period. Then overnight drainage when good urine output is established.

Overnight drainage is used on all new Urostomy patients within the hospital as it provides reassurance, comfort and allows them to sleep/recover from surgery.


If overnight drainage is used the catheter bag is emptied down the toilet, the tubing and bag washed through and left to dry so it can be re-used. Overnight drainage bags may last one month in the community. However, it is down to the patient’s preference and many patients will change their overnight drainage bag every 3-7 days. The indication for this is that the overnight bags may become discoloured, smell, or become blocked with mucus.

14.4 High Output Stoma

If a patient has a high or suspected high output from their stoma, please contact a Stoma Care Nurse, who will assess the patient and their output (see attached High Output Protocol – Appendix 1).

Patients with a high stoma output become dehydrated easily and can become malnourished so a strict Fluid Balance chart and a Food chart should be maintained. Many of these patients may also need to be referred to the ward Dietician.


Basic supplies of all of these are stored in a cupboard on 9West ward and may be accessed via one of the staff nurses.

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15. ACCESSORIES

The following products should not be used routinely, only as required and following advice from the stoma care nurse.

The following items are readily available for the problems as detailed.

15.1 Stomahesive Paste

This paste is used to fill in creases, creating a more even surface for the appliance to adhere to. It may sting on sore skin as it contains alcohol.

15.2 Cohesive Ostomy Seals

Hydrocolloid rings come in two sizes and possess adhesive properties on both sides.

(a) Small - It can be stretched to form a secure seal around the stoma and can be used for extra reinforcement.

(b) Large - It can be stretched or cut to protect a large area of skin, i.e. wounds, fistulae, drain sites and where a wound manager bag may need to be applied if the output is high (see Section 18.2).

15.3 Orahesive Powder

Hydrocolloid powder absorbs moisture and protects the skin. The powder itself is quite chalky and must be used sparingly. Too much will prevent the flange from sticking.

15.4 Orabase Paste

Hydrocolloid paste mixed with paraffin oil. It is used to protect the stomal edges where there is slight detachment, for ulcers, bleeding mucosa on a stoma, or a sore stoma. For a new stoma, which is dusky, it should be applied immediately to attempt reduction of oedema. It should not be used under adhesives as this will prevent the appliance adhering to the skin.

15.5 Ostomy Clips

To be used on drainable bags. There are several types available.


All the above items are stored in a cupboard on 9 West and can be accessed via a staff nurse.

If you are unsure of which accessory is required, please contact one of the stoma nurses for further advice or patient review.

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16. HOW TO MANAGE PROBLEMATIC SKIN CONDITIONS

16.1 Excoriated Skin

Whether this is caused through leakage or an ill-fitting appliance, it must be treated by protecting the immediate peristomal skin. Cutting the appliance to fit directly to the bowel wall edges is imperative. If the skin is excoriated please contact the stoma nurse who can advise on using appropriate barrier films (e.g. Cavilon sticks). Please refrain from using barrier creams as this may prevent the bag from adhering.

16.2 Skin Reaction

Can be caused by an allergy to the compounds within the flange. A skin reaction is evident when the flange is removed from the abdomen, revealing a well-defined area of redness, which outlines the shape of the flange.

Allergies to adhesives can occur at any time. This is treated by using a different product as each company uses different compounds to manufacture their products. Review after a couple of days and/or discuss with stoma nurses.

16.3 Itchy Skin

This can be a result of excoriation, peristomal skin being shaved too frequently, the use of perfumed soaps, bath lotions or excessive perspiration.

Orahesive powder should be applied sparingly over the peri-stomal area. Shaving should be reduced, so as to minimise the itching and barrier wipes/creams might be used. These are only available from the stoma care nurses.

16.4 Red or Broken Skin

Leaking ileostomies are a major cause of red, sore and broken skin. Other contributing factors may be;

the flange being removed too quickly the area being cleaned too vigorously dermatological conditions

If there is any evidence of broken skin, then it is important to use an appliance that can be left in place for several days. (If using a one-piece closed, then it is worth considering a two-piece, if the patient is able to manage).

Orahesive powder should be applied sparingly underneath the flange before application.

Adhesive Remover may also be used to prevent any further trauma to the area. This is available from the stoma nurse.

*If a dermatological condition exists (eczema, psoriasis) it may be necessary to consult a dermatologist. The stoma care nurses will assist with this decision.


17. POTENTIAL PROBLEMS ASSOCIATED WITH STOMA CARE

17.1 An appliance that is cut too small, may cause:

1) Friction or sheering of the stoma, which in turn causes bleeding and over granulation of the mucosa.

2) If the faecal matter is watery/loose, it will seep underneath and erode the flange, causing leakage and may potentially damage the peristomal skin.

3) The patient may experience pain and discomfort since the stoma is restricted.

4) With a colostomy, faeces may pancake underneath the flange forcing the appliance to leak or fall off.

5) Leakage, which in turn may lead to embarrassment, fear and loss of dignity for the patient.

17.2 An appliance that is cut too large, may cause:

1) In the case of a patient with an ileostomy, it may precipitate skin damage. The epidermal layer becoming red and broken, leaving nerve endings exposed and causing discomfort for the patient.

2) Overgranulation around the stomal edges.

17.3 Factors which may prevent good adhesion of an appliance:

1) Excoriated or damaged skin.

2) Skin allergies, i.e. eczema, psoriasis.

3) Failure to dry the peristomal skin properly prior to attaching the new flange.

4) Very dry skin.

5) Inadequate cleaning and removal of glue and faeces from the peristomal skin. It may also cause itching.

(Porrett, McGrath,2005)


18. THE MANAGEMENT OF ABDOMINAL FAECAL FISTULAE

18.1 Fistula: an abnormal passage connecting the cavity of one organ with another or a cavity with the surface of the body. Fistulae vary in size and activity

Output can also vary

If the fistula is small and its fluid production minimal, then we suggest a small drainable pouch be used. This will help maximise skin protection and contain the fluid

If the fistula is more defined and possibly situated in the middle of a laparotomy wound or adjacent to sutures and has a significantly large output, then we recommend a wound manager

Every effort should be made to ensure that a defined fistula is isolated from the remainder of the wound

18.2 Why are Wound Managers used?

1) To collect the faecal fluid, so it can be measured accurately.

2) To protect the skin from corrosive chemicals contained in the fluid.

3) So that the fistula can be inspected and cleaned regularly (the bags may have windows, which can be opened).

4) So that the patient is comfortable and experiences minimum distress (dressings would have to be changed frequently, which is time consuming and can cause the patient pain).


Wound Managers are used to facilitate drainage from large abdominal wounds/abdominal fistulae, when the output is such that it cannot be contained by dressings and where the exudate may damage the surrounding skin.

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18.3 What equipment do I need to apply a Wound Manager?

1) Warm saline

2) Cohesive seal

3) Stomahesive paste

4) Adhesive Remover

5) Incontinence sheets

6) Large yellow rubbish bag

7) Scissors

8) Suction equipment

9) Wound manager (appropriate size)

10) Gloves

11) Oxygen / Barrier Film (if skin is excoriated)


Wound managers are expensive (approx £20 per appliance).Do not use them unnecessarily.

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18.4 How do I apply a Wound Manager?

1) Help the patient back to bed if they are sitting out. Make them comfortable because this procedure can take 30-60 minutes.

2) Ensure the patient is protected by using incontinence sheets and ensure they are not unduly exposed. (NB: a lot of body heat may be lost especially via a large fistula).

3) Check the suction equipment is in full working order (you may need another nurse to assist you if the fistula is active).

4) Remove the wound manager from its packet and keep clean and dry.

5) Clean around and over the fistula and surrounding skin.

6) Take the wound manager and starting from the back (paper side) cut it to the exact shape and size of the fistula or wound you want to cover. Go round the opening again, giving extra space of 2-3 mm.

NB: If lots of skin is visible, then it has been cut too big and may reduce how long the appliance lasts.

(Remember to take your time, as these bags are expensive).

7) Cut Cohesive seal and stretch to fit around the wound. Large or small seals may be used according to the wound size.

8) Ensure that there is no fluid coming from the fistula to contaminate or moisten the Cohesive. It must be kept dry (use suction).

9) On top of the Cohesive apply stomahesive paste (from the tube) or from a syringe as the paste will dry more quickly.

10) Remove backing paper from the wound manager and apply it over the wound. Ensure that all areas have stuck to the skin by pressing it firmly into position working from the inside to the outside.

11) Take the syringe of paste and reinforce the margins around the inside of the bag, where the wound and Cohesive meet, so that no gaps are visible.

12) Put a little bit of air in the bag to prevent the surfaces sticking together whilst the paste dries. Close the window.

FISTULA MANAGEMENT IS HIGHLY VARIABLE. The Stoma Care Nurses will ensure that you have detailed instructions for care and every individual patient’s care will be documented in their care records.


FinallyThese guidelines are not an end point. Stoma Care and Fistula management will always vary with an individual’s needs, capabilities and management issues.

Please help the Colorectal and Stoma Care Team to help you, by ensuring that we are informed and by being willing to help and learn.

19. OBTAINING SPECIMENTS

Urostomy

Intervention Rationale

Wash hands with soap and water Prevent cross infection

Put on disposable gloves and disposable apron

Standard universal precautions

Inform the patient about the procedure and why the specimen needs to be taken

Gain informal consent

Remove Urostomy Bag Urine collecting systems can have bacteria present on its surface

Place sterile receiver bowl under stoma to collect sterile urine specimen

To collect sterile specimen

Transfer specimen into urine specimen container

For transfer of specimen to the laboratory

Replace the urostomy bag in line with trust guidelines

Patient comfort

Prevent leakage of urine

Remove gloves and apron and wash hands with soap and water

Prevent contamination and cross infection

Label the specimen container and ensure the microbiology request on Cerner is completed correctly

Optimise patient treatment and care

To avoid repetition

Decontaminate hands with alcohol hand rub

Prevent contamination and cross infection

Document the procedure.

Follow up and document the results and discuss with medical team

Record which tests have been requested

Best practice for obtaining a urine specimen is recognised as inserting a Foley catheter into the stoma. However, we would not recommend that anybody should do this unless they are competent and have done this procedure before. If in doubt contact the team or the Stoma Nurse. The above guidelines are deemed acceptable for safe practice.


Obtaining Stool Specimens from A Colostomy or Ileostomy

Obtaining a stool specimen from an ileostomy or colostomy is a similar procedure to gaining a normal stool specimen. Therefore please follow the current Trust policy, Infection Control – Specimen Collection, on obtaining a stool specimen.

20. SUPPORTING INFORMATION

1) Basic stoma care supplies are kept on 9 West. If you are unsure about what appliance to use, contact the stoma care nurses.

2) Additional supplies are kept in the stoma care nurse’s office. These are only available on the advice of the stoma care nurse

3) The stoma care nurses office is on 9 West

4) The stoma care nurses are available for advice:

Monday to Friday (08.00hrs – 16.00hrs)Extension 36872 or Bleep 1983


In the absence of the Stoma Care Nursesupport and advice can be obtained from the

Staff Nurses on 9 West and/or

the Colorectal Nurse on bleep 1367.

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21. REFERENCES

Black, P. (2000) Holistic Stoma Care. Balliere Tindall, London

Breckman, B. (2005) Stoma Care and Rehabilitation. Elsevier Churchill Livingstone, London

Cahon, M. (1999) Faecal Stomas, in: Porrett, T. and Daniel, N. (1999) Essential Coloproctolgy for Nurse. 165-187 Whurr Publishers Ltd, London

Cottam, J. and Richards, K. (2006) National audit of stoma complications within 3 weeks of surgery. Gastrointestinal – Nursing, 4(8) 34-39

Fillingham, S. and Douglas, J. (1997) Urological Nursing 3rd Ed. 217 Balliere Tindall, London

Fuller, N. and Lawrence, K. (1994) Obtaining a urine specimen from a conduit urostomy: this procedure is often performed incorrectly: here’s how to do it right. American Journal of Nursing, 94(1) 37

Porrett, T. and Daniel, N. (1999) Essential Coloproctology for Nurses. Whurr Publishers Ltd, London

Porrett, T. and McGrath, A. (2005) Stoma Care. Blackwell Publishing Ltd, Oxford


22. APPENDIX 1 PROTOCOL - MANAGEMENT OF HIGH OUTPUT STOMA / ENTEROCUTANEOUS FISTULA


Patient with faecal output > 800mls per 24 hours

ALL patients in this group Daily U + Es & URINE

Na+ Daily weight Accurate fluid chart Low fibre diet

OUTPUT 800 - 1200 mls OUTPUT > 1200 mls and above

IV Cannula +/- n/saline infusionIV Cannula + n/saline infusion

Restrict oral fluids to 1 litre maximum per 24 hours

Consider St Marks Solution

Restrict oral fluids to 500 mls - 1 litre maximum per 24 hours

Add salt to diet (crisps)

Eat Jelly Babies & Marshmallows

Consider St Marks Solution

Only sip fluids with meals and drink 1 hour before and after eating

1 Litre St Marks Solution

Loperamide – 30 mins prior to meals. Start 4mg QDS and increase if output does not reduce – 12mg QDS maximum

Consider codeine phosphate/PPI’s Add Salt. Try Jelly Babies & Marshmallows

Only sip fluids with meals and drink 1 hour before and after eating

Discuss with dietician/nutrition team+ Weight loss please refer to dieticianIf output above 1000mls

Loperamide - Start 2 – 4mg TDS + then increase if output does not reduce

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The Royal Free Hampstead NHS Trust

Colorectal / Stoma Care Nursing Service

Management of a High Output Ileostomy / Enterocutaneous Fistula

1.0 SummaryThis guideline outlines the general principles only to be followed by medical and nursing staff caring for a patient with a high output ileostomy or enterocutaneous fistula.

2.0 NarrativeWater and sodium absorption in the small intestine is enhanced by the presence of the ileo-caecal valve, the colon and by nutrient absorption. Water absorption in the small bowel is dependent on the osmolarity of the fluid in the lumen and sodium absorption is dependent on the concentration of sodium in the effluent and the absorption of glucose.

Fluids low in sodium passing through the duodenum and jejunum attract sodium from the cells increasing the sodium of the small bowel effluent which is passed directly out of the stoma (at the terminal ileum). A high fluid and sodium output from the small bowel (via a fistula or ileostomy) will lead to a decrease in the selection reabsorption of potassium in the kidney nephron.

The sodium concentration of effluent from an ileostomy = 100-150mmol per litre.

It is difficult to ingest and absorb more than 200mmol of sodium daily.

Intravenous fluids contain:1,000mls saline 0. 9% = 154 mmol sodium1,000mls dextrose saline 4% = 30mmol sodium

For the purpose of these guidelines the definition of a high output ileostomy is one with an output in excess of 1200mls in 24 hours.

Normal rate = 500-800mls in 24 hours.

Common Signs of Sodium Deficiency apathy poor skin tone dark ringed eyes low volume pulse – tachycardia dizziness on standing due to postural hypotension muscle cramps thirst

Guidelines for Practice1. Intravenous infusion in situ to maintain serum sodium above 140mmols2. Restrict oral fluids to 500mls in 24 hours. Discourage patient from taking a

volume of fluid 30 minutes before meals and for approximately one hour afterwards. However, for patient comfort sips may be taken.

3. Substitute water and low sodium drinks, i.e. tea and coffee, with isotonic solution.

4. ST MARK’S SOLUTION

RationaleReduction of volumes of fluid will deter gut irritability which has a positive impact on transit time. Drinking large amounts of fluids with meals encourages food to pass rapidly through the gut.

The isotonic solution will facilitate re-absorption of water and salt.

5. Encourage food intake gradually keeping the diet low residue. Foods to encourage - white bread, rice, mashed potatoes, bananas. Avoid soup and ice cream.

RationaleHigh fibre foods, e.g. vegetables, may increase intestinal loss. Starchy foods help to thicken the effluent, making stoma management easier. Dairy products may cause bloating and flatus.

If medications are required to reduce gut transit timethey should be given 30 minutes prior to the food.

ExamplesLoperamide: 4 – 12mg QDS – 30 minutes prior to food. Increase gradually to TDS, QDS If output remains high increase to 4mg QDS Maximum 48mg in 24 hours for high output fistulas (can go higher but you must

speak with both Nutrition team and Colorectal/ Gastroenterology teams managing the patient).

Consider high dose oral PPI eg Omeprazole 40mg bd Consider adding codeine phosphate max 240mg in 24 hours. 30 – 60mg QDS Consider Octreotide 200mcg BD or TDS. If no clinically significant reduction in

output evident after 5-8 days discontinue Octreotide treatment.

To monitor treatmenta) Patient should be weighed daily at the same time wearing the same clothing.b) Strict fluid balance volume and consistency of stoma output.


Equality and Health inequalities Impact Assessment Screening Checklist

Name of policy/service Stoma Care GuidelineIs this a new or existing policy/service

Review of existing policy

Purpose of the policy/service To provide guidelines to staff to ensure quality of practiceStakeholders in policy/service development

See validation grid

Person responsible for policy/service impact assessment

Louise Foulds and Annalyn Manalastas

Proposed date for implementation of policy/service

August 2009

Do you think the policy/service will impact upon any group within the population based upon:

Race/ethnicity No Lower socio-economic groups No

Gender No Involvement in the criminal justice system No

Religion/belief No Homelessness No

Disability (including long term conditions and mental health)

YesLooked after children

No

Age No Population groups more at risk of developing certain conditions (based on community health profile data)

No

Sexual orientation or gender identity No Any other groups No

What impact will the policy/service have on lifestyles? For example: Diet and nutrition Exercise and physical activity Substance use; tobacco, alcohol, drugs Risk taking behaviour Education and learning or skills Functional ability Quality of life

Will the policy/service have any impact on the social environment? For example: Social status Employment (paid or unpaid) Social/family support Stress Income

Will the policy/service have any impact upon: Discrimination? Equality of opportunity? Relations between groups? Improving uptake of services by under represented groups?

Will the policy/service have any impact on the physical environment? For example: Living conditions Working conditions Pollution or climate change Accidental injuries or public safety Infection control

Will the policy/service impact on access to and experience of services? For example: Healthcare Transport Social services Housing services Education

jk07 08/04/2023

Equality impact assessment screening checklist summary sheet1. Positive impacts (Note groups affected)

The policy aims to achieve effective, safe and individualised stoma care management for all groups concerned, and provide the best quality of care possible for all groups.

2. Negative impacts (note groups affected)

The policy does not have a negative impact on any patient groups. It promotes best practice and high quality care for all groups.

3. Additional information/evidence required

No further information required.

4. Recommendations

To review policy regularly and ensure best practice and quality care is implemented for all groups.

5. As a result of completing the impact checklist, have any negative impacts been identified, and if so

is a full impact assessment recommended?

None identified.

6. If impact assessment has not been recommended please state the reasons why.

No negative impacts identified, therefore full impact assessment not indicated.

Date for completion of screening checklist review /completion of full impact assessment :

August 2009

Managers name and signature:

Lesley Mattin

Date:

August 2009

Approved by Operational manager for Equality and Diversity(name and signature)

Jennifer Kenward

Date:

04.11.09

jk07 08/04/2023

Salt & Son Ltd 08/04/2023

965_Stoma Care Guidelines 2009

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Transcript of 965_Stoma Care Guidelines 2009