What is the management plan for a patient with a stoma?

Management Plan for a Patient with a Stoma

Comprehensive stoma care requires multidisciplinary coordination with wound ostomy and continence (WOC) specialists to prevent complications, manage expectations, and improve quality of life for patients with ostomies. 1

Preoperative Care

• Preoperative education and stoma site marking by WOC specialists improves quality of life and decreases peristomal skin and pouching complications 1
• Optimal stoma placement should be within the rectus muscle and away from scars, skin folds, bony prominences, and the umbilicus 1
• Psychological preparation should address concerns about leakage, odor, clothing, intimacy, and self-care 1

Immediate Postoperative Stoma Care

• Apply minimal traction to the external fixation plate without tension immediately after stoma placement 1
• Monitor the stoma site daily for signs of bleeding, pain, erythema, induration, leakage, and inflammation 1
• Clean the stoma site with 0.9% sodium chloride, sterile water, or freshly boiled and cooled water 1
• Use a sterile Y dressing under the external disc plate, followed by a skin-friendly, solvent-free breathable dressing 1
• Avoid occlusive dressings as they promote moisture and can lead to skin maceration 1

Ongoing Stoma Care (After Healing)

• Once the stoma tract has healed (approximately one week), rotate the tube daily and move it inward at least once a week (2-10 cm) 1
• Return the tube to its initial position with 0.5-1 cm free distance between the skin and external bolster 1
• For healed stomas, cleanse twice weekly with soap and water, and reduce dressings to once or twice a week 1
• For gastrojejunostomy or gastrostomy with jejunal extension, do not rotate the tube (only push in and out weekly) 1

Managing Common Complications

Peristomal Skin Issues

• For peristomal leakage, use zinc oxide-based skin protectants 1
• For allergic reactions (presenting as itching and redness in the shape of the appliance), apply skin sealant for minor irritation or consider changing the pouching system and using temporary steroid spray 1
• For fungal infections (itchy maculopapular rash with satellite borders), sprinkle antifungal powder onto the skin and seal with sealant 1
• Refer patients to a surgeon or enterostomal therapist if no improvement after 2 weeks 1
• For patients with IBD presenting with painful ulcers surrounded by a purple halo, assess for peristomal pyoderma gangrenosum 1

Stomal Prolapse

• For non-ischemic prolapse, reduce by laying the patient in a relaxed position and gently squeezing the ostomy back into the abdomen 1, 2
• If manual reduction fails, apply a cup of sugar directly to the stoma and leave for 20 minutes 1
• For acute prolapse with ischemia (presenting as pain, obstipation, and purple/black discoloration), arrange emergency surgery 1, 2

Parastomal Hernia

• Small, reducible parastomal hernias can be managed with a hernia belt 1
• Consider elective repair for significant pouching issues, pain, or recurrent bowel obstruction 1
• The most effective repair is ostomy reversal when possible 1

High Output Management

• For high output stomas, restrict oral hypotonic fluids to less than 500 ml daily 1
• Encourage drinking glucose-saline solution (sodium concentration ≥90 mmol/L) throughout the day 1
• Consider antimotility medications like loperamide before meals to reduce intestinal motility 1

Long-term Follow-up

• Maintain regular communication between patients and care teams 1
• Connect patients with community-based and online ostomy support groups 1
• Monitor for quality of life issues as many patients experience changes in lifestyle (80%) and sexual difficulties (>40%) 3

Common Pitfalls to Avoid

• Encouraging excessive oral fluid intake can paradoxically increase stomal sodium losses 1
• Failing to address psychological impacts can lead to poor adjustment and quality of life 1, 3
• Neglecting regular stoma site assessment can result in delayed identification of complications 1, 4
• Using occlusive dressings promotes moisture and can lead to skin maceration 1
• Improper tension between bolsters can contribute to buried bumper syndrome and other complications 1