What is the first line of management for a patient with a stoma?

First-Line Management of a Patient with a Stoma

The first-line management for a patient with a stoma is preoperative wound ostomy and continence (WOC) nurse consultation with stoma site marking, followed by comprehensive patient education on proper stoma care techniques and appliance management. 1, 2

Preoperative Priorities

Preoperative stoma site marking by WOC nurses is the single most important intervention to prevent complications and improve quality of life. 1, 2 This evidence-based practice has been shown to:

• Decrease peristomal skin complications 2
• Reduce pouching problems 1
• Improve overall quality of life outcomes 1

The marking process involves assessing the abdomen in multiple positions to identify a site within the rectus muscle, away from scars, skin folds, bony prominences, and the umbilicus. 1

Initial Postoperative Stoma Care

Immediate Care (First 24 Hours)

• Monitor the stoma exit site daily for signs of bleeding, pain, erythema, induration, leakage, and inflammation 1
• Cleanse the site with 0.9% sodium chloride, sterile water, or freshly boiled and cooled water 1
• Apply a sterile Y dressing (non-fiber shedding) under the external disc plate, followed by a skin-friendly, solvent-free breathable dressing 1
• Avoid tension when placing dressings under the exterior bumper 1
• Never use occlusive dressings as they promote moisture and skin maceration 1

After One Week (Once Healed)

• Reduce cleansing frequency to twice weekly using clean cloth with fresh tap water and soap 1
• Dry the skin gently and thoroughly after cleansing 1
• Allow normal activities including showering, bathing, and swimming (with waterproof dressing for public pools) 1

Patient Education: Critical First-Line Components

Psychological Support

Address the psychological impact immediately as concerns about leakage, odor, disclosure, intimacy, and self-care significantly affect quality of life. 1, 3 More than 40% of patients experience problems with their sex lives, and 80% experience lifestyle changes. 3

Appliance Management

The most frequent cause of peristomal skin damage is leakage from poorly fitting appliances. 2, 4 First-line prevention includes:

• Ensuring proper appliance fit to prevent effluent leakage 1, 2
• Teaching patients to recognize early signs of leakage 1
• Providing clear written and visual materials for caregivers 1

Managing High-Output Stomas

If stoma output exceeds 1200 mL daily, implement these first-line interventions immediately: 1

• Restrict hypotonic oral fluids (water, tea, coffee, fruit juices, alcohol) to less than 500 mL daily 1
• Avoid hypertonic fluids (fruit juices, Coca-Cola, commercial sip feeds) that increase stomal losses 1
• Provide glucose-saline solution with sodium concentration of at least 90 mmol/L (WHO cholera solution) to sip throughout the day 1
• Add extra salt to food at the table and during cooking for outputs of 1200-2000 mL 1

Common Peristomal Skin Complications: First-Line Management

Allergic Contact Dermatitis

• Apply skin sealant for minor irritation 1
• Change the pouching system if irritation persists 1
• Use temporary steroid spray for symptomatic relief 1

Fungal Infections

• Sprinkle antifungal powder on the affected skin 1
• Seal with skin sealant over the powder 1
• Refer to surgeon or enterostomal therapist if no improvement after 2 weeks 1

Critical Pitfalls to Avoid

• Never encourage patients to drink large amounts of hypotonic fluids to quench thirst—this dramatically increases stomal sodium losses and can lead to rapid dehydration 1
• Do not apply excessive traction to newly placed stomas, as this increases risk of buried bumper syndrome 1
• Avoid moving the stoma location when repairing parastomal hernias, as the new location carries significant risk of recurrence 1

Establishing Ongoing Care

Provide clear identification of emergency contact points before discharge, specifying which department or service can provide urgent advice. 1 Multidisciplinary coordination between WOC nurses, surgeons, and primary care providers is imperative to prevent readmissions and maintain quality of life. 1