What is the best approach for wound care in a patient with a stoma?

Stoma Wound Care

For the first week after stoma creation, perform daily aseptic wound care with sterile cleansing and breathable dressings, then transition to simple soap and water cleansing 1-2 times weekly once healed. 1

Initial Week: Intensive Care Protocol

During the first 7 days post-operatively, implement strict aseptic technique with daily monitoring:

• Cleanse the stoma site daily using 0.9% sodium chloride, sterile water, or freshly boiled and cooled water 1
• Apply sterile Y-dressings under the external fixation plate to absorb drainage and cushion movement 1
• Use only breathable, skin-friendly, solvent-free dressings over the site—never occlusive dressings, as these trap moisture causing skin maceration and infection 1
• Inspect daily for bleeding, pain, erythema, induration, leakage, and inflammation during tract formation 1

Cost-Effective Alternative Approach

Consider glycerin hydrogel dressings as a superior first-week option (Grade B evidence):

• Apply the hydrogel dressing the day after stoma placement 1
• Change weekly rather than daily during the first 4 weeks 1
• This approach significantly reduces infection scores compared to standard daily dressings 1

After Week 1: Maintenance Care

Once the stoma tract is formed and incision healed (typically 7-14 days):

• Reduce dressing changes to 1-2 times per week 1
• Cleanse with simple soap and tap water of drinking quality 1
• Use a simple plaster around the wound, or omit dressings entirely and leave the site open 1
• Thoroughly dry the peristomal skin before applying new dressings or appliances to prevent breakdown 1

Managing Peristomal Skin Complications

The most frequent cause of peristomal skin damage is effluent leakage from poorly fitting appliances 2. When leakage occurs:

• Apply zinc oxide-based skin protectants, barrier films, pastes, or creams to prevent breakdown 1
• Use foam dressings rather than gauze to lift drainage away from skin while preventing maceration 1
• Cut the appliance opening one-eighth inch larger than the stoma to prevent mucosal irritation while limiting skin exposure to effluent 3
• Heat the appliance with a hair dryer before application, lie flat for several minutes after application, and ensure the peristomal skin is completely dry 3

Additional pouching techniques to prevent leakage include convex appliances, ostomy belts, paste, or barrier rings 3. Fine dusting of stomal powder followed by skin sealant on peristomal skin before application can also help 3.

Bathing and Water Exposure

Showering, bathing, and swimming are permitted once the stoma site is properly healed (approximately one week or more after surgery):

• Use waterproof dressing for public pools or shared bathing facilities 4
• Ensure the peristomal skin is completely dry before reapplying the ostomy appliance after bathing 4
• Cleanse the stoma site with fresh tap water and soap after bathing 4
• Inspect for signs of infection (erythema, purulent discharge, or skin breakdown) after bathing 4

Critical Pitfalls to Avoid

• Excessive tension on external fixation plates causes tissue ischemia and buried bumper syndrome—maintain 5mm free movement 1
• Insufficient incision size creates pressure necrosis—ensure adequate opening 1
• Occlusive dressings trap moisture and cause maceration—always use breathable materials 1
• Failure to mobilize the tube after healing leads to adhesions—push tube 2-3cm inward and rotate daily after week 1 1
• Inadequate drying after cleansing promotes skin breakdown—thoroughly dry before applying new dressings 1

High-Risk Patients Requiring Extended Care

Patients with impaired wound healing need extended intensive monitoring beyond 7 days:

• Diabetes, immunosuppression, malnutrition, ascites, or corticosteroid use require daily monitoring beyond the standard first week 1
• Watch for delayed tract formation, which may take up to 14 days instead of 7 1
• Treat local fungal infections with topical antifungals if they develop alongside leakage 1

When to Escalate Care

Return to daily intensive wound care if any of the following develop after initial healing:

• Increased erythema, purulent drainage, or persistent leakage 1
• Fever, increased pain, or induration suggesting infection 1
• Difficulty mobilizing the tube or hypergranulation tissue formation 1

Role of Preoperative Planning

Preoperative stoma site marking by wound ostomy and continence (WOC) nurses decreases peristomal skin complications and improves quality of life 3, 2. Marking allows assessment of the abdomen in multiple positions for a site within the rectus muscle, away from scars, skin folds, bony prominences, and the umbilicus 3. This single intervention has been shown to improve quality of life and decrease both peristomal skin and pouching complications 3.