The purpose of this guideline is to provide guidance about stoma care at Great Ormond Street Hospital.
Stoma formation in childhood is performed during the surgical correction of congenital abnormalities, following trauma and/or to defunction the bowel, treatment of inflammatory bowel disease, intestinal motility disorders, infections e.g. necrotising enterocolitis and malignancy of gastrointestinal tract or urinary system.
There are three main types of output stomas:
Ileostomy: a portion of ileum is brought out through the abdominal wall and is normally sited in the right iliac fossa.
Colostomy: a portion of the colon is brought through the abdominal wall and is normally sited in the left iliac fossa (the transverse, descending or sigmoid colon may be used).
Vesicostomy: the neck of the bladder is brought through the abdominal wall low down in the pelvis.
Ureterostomy: one or two of the ureters can be brought out to the abdominal wall either side by side or at either side of the abdomen or flanks.
- Ileal conduit: a small segment of ileum is isolated to act as a reservoir and the ureters implanted into it. This stoma can be sited either in the left or right iliac fossa.
There are many different pouches produced by a number of manufacturers. Using an inappropriate pouch is time-consuming and can cause needless discomfort for the patient (Burch 2014).
There are basically two designs of pouch:
- A one-piece pouch has an adhesive flange with a pouch bonded onto it.
- A two-piece pouch has an adhesive flange and a separate pouch, which attaches to the flange.
Both the one piece and the two-piece pouch can have a closed end or an open or drainable end (Rationale 1).
Urinary pouches have non-refluxing valves and an adaptor to attach to an overnight drainage bag (Rationale 2).
Children with colostomies, which produce formed stool, have the opportunity to use a colostomy plug:
- A faceplate is attached to the skin and a plug is inserted into the stoma. A cap on the end of the plug is then clipped onto the faceplate.
- The plug has to be removed at least twelve hourly and a bag attached to the faceplate (Rationale 3).
In the early post-operative period a one piece, drainable transparent pouch should be applied (Rationale 4).
The majority of stoma formation in childhood is carried out in the neonatal period. Stomas are generally a temporary measure until definitive surgery is performed. Babies do not have their stomas sited as they are formed during an emergency surgery.
Time and consideration should be spent ensuring the optimal site is marked. The following points should be considered:
- The child should be able to see the stoma (Rationale 6).
- The stoma should be placed within the rectus abdominus sheath (Rationale 7).
- Any bony prominences must be avoided (Rationale 8).
- Any previous scars, skin folds or creases must be avoided. There should be enough flat surface around the stoma for the pouch to adhere (Rationale 9).
- The waistline of clothes must be avoided (Rationale 10).
- Ensure that any prostheses or braces do not cover the site (Rationale 11).
- If the child is wheelchair bound, the stoma must be sited while he/she is in the wheelchair (Rationale 12).
Changing the stoma pouch
Gather appropriate equipment: (Rationale 13)
- receptacle to empty the pouch into
- disposable gloves (for hospital staff)
- non-alcoholic adhesive remover
- bowl of warm water
- gauze squares or cleansing wipes
- new pouch
- bag to dispose of the used pouch and cleansing materials
- template or measuring device
Position the child. Babies should lie down, older children may lie down or stand up (Rationale 14).
Wash hands and put on disposable gloves. If a drainable pouch is used it needs to be emptied prior to removal (Rationale 15). The output should be measured, with volume and consistency documented on fluid chart.
Remove the old pouch by carefully peeling it off from top to bottom with one hand, whilst supporting the skin with the other. Only use non-alcoholic adhesive removers if required - adhesive removers with alcohol should not be used on small babies (Stephen-Haynes 2008) (Rationales 16 and 17).
The old pouch should be disposed of in a orange clinical waste bag (Rationale 18).
Clean the peristomal skin with warm water and gauze. If some residue is left on the skin from the old pouch, use a dry piece of gauze to remove it before washing. Do not use cotton wool. Ensure the skin is dried thoroughly (Rationale 19).
Prepare the new pouch. The aperture should be cut to fit snugly around the stoma with no peristomal skin exposed. A template or measuring device can be used for this (Rationale 20).
Put on the new pouch.
If a one-piece pouch is being used, fold the adhesive backwards in half, placing the pouch on the underside of the stoma first, then flip the adhesive over the stoma and secure all around.
If a two-piece pouch is being used secure the flange first and then attach the pouch. Pull the pouch gently to ensure it is attached completely (Rationale 21).
If a drainable pouch is being used ensure the clip is secured correctly (Rationale 22).
Dispose of all equipment in accordance with the Trust Waste Management Policy (Rationale 18).
Document care in child's health care record.
Potential problems with stomas
There can be problems with stoma management in paediatric patients (Rationale 23). In the post-operative period a drainable transparent pouch is used so that the stoma can be observed easily, the main observation should be the colour of the stoma. Any concerns should be reported and recorded in the patient's notes.
A healthy stoma is red/pink in colour. It is very important, especially in the postoperative period, to check the colour of the stoma regularly. If the stoma appears darker in colour medical advice should be sought (Rationale 24).
In the early postoperative period all stomas will be oedematous. Parents and children should be aware that the stoma will change shape and size. At six weeks the stoma should have shrunk to its actual size. This is important as the parent/child needs to cut the pouch or flange to the exact size of the stoma (Rationale 25).
Prolapse of loop stomas in infants and children is common. Parents and children need to be advised of the possibility, given a description of what a prolapse looks like, and when to seek medical advice (Rationale 26).
Older children should be discouraged from lifting heavy weights (Rationale 27).
Some stomas can become retracted. This will cause more problems with an ileostomy as the output is loose, and stool will leak under the adhesive of the pouch. Parents can seek the advice of the stoma nurse or the doctor if the stoma appears sunken (Rationale 28).
Stenosis of the stoma can also occur. Often the narrowing of the bowel is at the skin surface, but it can occur inside the abdomen. This may present with:
- a reduction in the amount of stool passed
- stools may appear ribbon-like
- the passage of stools may cease (Rationale 29)
Nodules of granulation tissue can form on the surface of the stoma. These can bleed easily and may cause concern, as they will bleed whenever the stoma pouch is changed (Rationale 30).
Rationale 1: Closed end pouches are used when stools are formed. Open ended or drainable pouches are used for loose stools.
Rationale 2: Non-refluxing valves prevent urine from washing back into the stoma.
Rationale 3: The plug is taken out to allow the bowel to empty.
Rationale 4: It is important to observe the colour of a newly fashioned stoma. Applying a two-piece pouch may be too painful to apply. Stools will also be loose in the early post-operative period.
Rationale 5: If the stoma is placed in the optimal position the child should find stoma management easier.
Rationale 6: As he/she gets older the child will learn to change the pouch and will therefore need to see the stoma, both lying down and standing up.
Rationale 7: This muscle should grip the stoma preventing retraction, or herniation.
Rationale 8: If the stoma is too near the hip, movement will pull the pouch off.
Rationale 9: Skin creases, folds and scars make the skin surface uneven. Loose stools will leak along these tracts.
Rationale 10: Stomas should be under the waistline of clothes, both for discretion and pouch security.
Rationale 11: Any appliances worn can usually be adapted so as not to interfere with the pouch.
Rationale 12: To identify a visible position and ensure the child’s comfort.
Rationale 13: To be prepared to carry out procedure without interruption.
Rationale 14: The child needs to be comfortable. When sitting up the abdomen becomes too wrinkled to apply the pouch securely.
Rationale 15: To adhere to standard precautions. Unless it is emptied first the pouch contents will spill. When at home full pouches should not be placed in the general refuse.
Rationale 16: Supporting the skin makes the procedure less uncomfortable and helps prevent the skin from tearing.
Rationale 17: Adhesive removers can dry out the skin causing soreness.
Rationale 18: To adhere to trust waste disposal policy.
Rationale 19: The residue will spread over the skin if wet. Any residue left on the skin may interfere with the adhesion of the new pouch. Cotton wool will deposit strands, which may interfere with pouch adhesion.
Rationale 20: With a well-established stoma the pouch can be prepared beforehand. If any skin is exposed to stoma output it will become excoriated.
Rationale 21: Two-piece pouches will leak if the pouch has not been attached properly to the flange.
Rationale 22: If the clip is not secure the pouch will fill up and subsequently leak.
Rationale 23: The majority of children with stomas are neonates and a large percentage are premature. In this age group complications are high.
Rationale 24: If the blood supply is compromised the bowel will become necrosed. The stoma will become much darker in colour ie purple/black. Surgical refashioning of the stoma may be necessary.
Rationale 25: Only one or two pouches should be prepared at a time. This will ensure the pouches are not cut too big, exposing peristomal skin to the stoma output as the stoma shrinks. Families are advised to wait six weeks before arranging precut pouches or having pouches/flanges cut by prescription companies.
Rationale 26: If the prolapsed bowel remains red/pink and soft there is usually no cause for concern. If the colour changes, ie becomes darker or the bowel is tense to the touch, medical advice should be sought. Some prolapses require reduction under sedation or general anaesthetic.
Rationale 27: Lifting heavy weights puts strain on the abdomen and can cause prolapse or parastomal hernia.
Rationale 28: Retracted stomas can be managed by using a pouch with a convex adhesive flange, which will push out the stoma. If this fails and the stoma becomes unmanageable, it may need surgical refashioning.
Rationale 29: Simple dilation of the stoma may solve the problem. If this does not work surgical revision of the stoma may be undertaken.
Rationale 30: Silver nitrate sticks can be used on the granulomas. If this does not work they can be removed surgically.
Burch J (2014) Stoma care in the community. British Journal of Community Nursing Aug 19(8): 396,398,400
Rust J (2009) Understanding the complexities of the clinical nurse specialist: A focus on stoma siting. Gastrointestinal Nursing 7(4): 18-25
Stephen-Haynes J (2008) Skin integrity and silicone: Appeel 'no-sting' medical adhesive remover. Br J Nurs 17 (12): 792-5
Breckman B (2005) Stoma care and rehabilitation. Oxford, Elsevier Churchill Livingstone