Introduction

There are a range of conditions that may require stoma formation including anorectal malformations, Hirschsprung disease, intestinal atresia, necrotizing enterocolitis, inflammatory bowel disease, cancer, bowel obstruction and spontaneous ileal perforation.  The stoma formation may be in response to a single congenital malformation or in the context of a more complex condition or injury.  In some situations, the stoma may be closed prior to discharge from hospital, alternatively the patient may be discharged home with the stoma in-situ.

Post-operative management of the child depends on their age, underlying condition and the procedure performed and may include monitoring of fluids and electrolytes, as well as management of nutrition and pain relief.  Another focus of care is the successful re introduction of enteral feeding.  The success of enteral feeding is dependent on multiple factors, including the pre-operative condition and age.  Post-operative complications may be related to wound healing ability, length and type of gut retained, further deterioration of surviving gut, stricture formation and sepsis, as well as individual characteristics.  Each of these may impact on the child’s hospital journey.

To guide practice for all children returning post-operatively with a stoma including:

• Initial post-operative assessment and management of the newly formed stoma.
• Management of complications and common problems associated with stomas

Definition of Terms 

Colostomy: a part of the large bowel is diverted out through the abdomen. 

Ileostomy: a part of the small intestine is diverted out through the abdomen (usually on the right side of the abdomen. Output is liquid and may look undigested.

Jejunostomy: more proximal small intestine section brought through the abdomen.  Output may be very watery and corrosive.

Mucous fistula: the other end of the non-functioning bowel brought through the abdomen – the distal bowel end.

Stoma: comes from the Greek word meaning mouth or opening. Often on the abdomen, may be connected to the intestine or urinary system. 

Types of stomas 

• Double-barreled: usually a temporary ostomy with two openings, one distal and one proximal.  Elimination occurs via the proximal opening, with the distal portion of the bowel able to rest and heal.  When healing is complete, the two ends are re-anastomosed and returned to the peritoneal cavity with the aim of returning bowel function.
• Loop: a loop of the bowel is brought through an opening in the abdominal wall, with an opening created in the apex of the bowel to allow emptying of contents.
• End: The bowel is completely separated and bought out as an end. The other end of the bowel can be bought out as a mucous fistula or completely closed over and left in the abdomen.

Assessment

• Observations as per Routine Post Operative Observation Guideline, Nursing Assessment guideline.
• Assess and manage post operative pain as per RCH Nursing Guideline: Pain assessment and measurement & RCH Nursing Guideline: Neonatal Pain Assessment.
• All preterm neonates and some infants will return postoperatively with Jelonet^TM and gauze over the stoma.
  • Observe the stoma when completing the dressing change or as directed by medical team and/or stomal therapy.
• Infants/children/adolescents will return with a stoma appliance/bag insitu.
  • Stoma observations should occur upon return to ward ½ hourly with routine post anesthetic observations and at 1-4 hourly thereafter as directed by the medical team and/or stomal therapy.
• The laparotomy suture line should have an adhesive dressing cover which should remain intact until surgical direction to remove, usually 5 to 7 days.
• Document stoma observations and laparotomy site assessment in the LDA flowsheet or avatar. 
  

Stoma Observations

Colour

• Red stoma/dark pink indicates adequate blood supply/healthy
• Pale pink indicates diminished haemoglobin or poor perfusion
• Dark red/purplish may indicate bruising.
• Grey to black indicates ischaemia and potential necrosis – immediate surgical review required

Appearance

• Healthy - red/pink and moist.
• Injurious - lacerations may occur due to handling
• Shape – round, oval, irregular

Protrusion

• Normal - above skin line 0.5 – 1 cm approximately/protruding
• Flush - at the level of the skin
• Retracted - below skin level
• Prolapsed - protrusion of stoma more than 2-3cm

Mucocutaneous Junction (where the stoma meets the skin)

• Intact– Sutures intact all the way around.
• Separated – an area of stitches has become separated

Periostomal skin (the skin around the stoma)

• Colour - healthy (should be the same as “normal” skin), erythema, bruising
• Integrity - intact, macerated, eroded, rash, ulcer, incision
• Turgor - soft, elastic, flaccid, firm

Wound

• Consider wound bed, measurement, edges, exudate, infection, surrounding skin, pain
• Refer to RCH Nursing Guideline: Wound Care if further information required

If you are concerned about the appearance of the stoma, please notify the medical team. 

Considerations for Ongoing assessment/management  

• Monitor and document stoma losses. High losses of 20mLs/kg/day or more should be reported to the medical team. Fluid replacement may be necessary.
  • Documentation of losses can be documented via the fluid balance or LDA flowsheet.
• A nasogastric or orogastric tube may be insitu postoperatively and open to free drainage.  Never clamp the NGT unless directed by the surgical team.
  • Gently aspirate the NGT/OGT every 4 hours until feeding commences.  Document separately as “aspirate” and “drainage” in the Fluid Balance section of the EMR Flowsheets.
  • If feeding commences via this tube, consider clamping for up to an hour post feed/medication administration then venting as appropriate.
• Some patients may require TPN until the stoma becomes active.
  • Feeds will increase at a rate determined by medical staff. Gradings should be assessed for tolerance and symptoms of feed intolerance, report concerns to the ANUM and medical team.  

Stomal Therapy

Stomal Therapy consultants should receive an EMR referral from the surgical team when a stoma is newly formed. Nursing staff caring for an infant with a stoma should ensure this has occurred so the infant may be followed-up and reviewed as required.   

Stomal Therapy are involved in education for parents and children with stomas and provide the education they require for discharge home safely and organise their linking in with Ostomy associations.

Stomal therapy should be notified if complications arise and when needing advice regarding dressings or product modifications are required.  Stomal therapists do not attend routine dressing or bag changes.

Nursing staff should check all patients with a stoma have a referral to stomal therapy in place.

There are 2 Stomal Therapy Departments within RCH

Stoma Management

Neonates/infants on Butterfly

• Will have a dressing insitu post operatively and require 4 hourly stoma dressing changes at a minimum, moving to 4-6 hourly PRN as assessments and stomal characteristics change. See Inactive stoma dressing change below for more information.
• If appropriate neonates/infants will change from a dressing to a stoma appliance as per stomal therapy direction. This may occur when stoma is active and meconium has passed.
  

Infants/Children/Adolescents

• Will have a stomal appliance insitu post operatively and these can stay intact unless leaking. If/when an appliance change is necessary, please see procedure for bag/application change.
• Where possible the first appliance change should be completed by stomal therapy for stoma assessment and product selection.

If the wafer and bag are secure with no evidence of leakage, the bag can be opened from the bottom and emptied every 4 hours. Document output on the fluid balance flowsheet.

For neonates a syringe with white tipped aspirator may be used to remove contents. 

Inpatient wards should have some ostomy appliances and supplies, but you may need to contact the Stomal Consultant for further products.

Product descriptions

Bag/Application Change

Neonatal and Pediatric appliances in Australia are available from 5 companies. There are Hollister Premmie Bags™ available to be used in the premature neonatal population. 

Please note this is a guide only, often application of a bag/appliance requires an individual approach. Follow all documented plans by stomal therapy. Peristomal skin issues, such as excoriation, should be reported to stomal therapy as these patients this may require additional input/support.

Inform patient/parent and prepare the patient. See RCH Nursing Guideline: procedure management.

Perform hand hygiene, and onto a clean trolley or work surface

Prepare equipment:

• warm water/saline or cleanser wipes
• new appliance to apply
• pattern and scissors to cut out new appliance. Cut to size.
• Accessories (moldable seals, paste strips, remover wipes/spray, hydrocolloid powder if using,
• Flextend® tape)
• Waste bag

Method:

1. Perform hand hygiene and don gloves.
2. Gently remove appliance using an adhesive remover wipe/spray. Keep appliance to measure output.
3. Perform hand hygiene.
4. Gently clean stoma and peristomal skin.
5. Pat dry surrounding peristomal skin, apply powder and/or warm the seal/ring with palm of hand and apply around stoma if using these accessories.
6. Remove backing from appliance and gently place over stoma onto seal/ring if using one.
   • If using a two piece appliance, apply wafer first then click bag in place
   •  You may angle the appliance on the side of the abdomen as it is easier to empty.
7. Place palm of hand over stoma to get good adhesion. The warmth of your hand and their tummy will assist to get a good seal.
8. Ensure there is some air in the appliance to prevent a vacuum prior to sealing the end of the appliance.
9. Remove gloves and perform hand hygiene.
10. Clean trolley or work surface, dispose of waste and perform hand hygiene. 
    

Inactive stoma dressing change 

A stoma dressing may be insitu if a stoma is inactive or if an appliance is unable to be used for example in cases of extreme excoriation of peri-stomal skin due to bag leakage or inverted or flush stomas.

The aim of the dressing is to keep the stoma clean and moist and to measure fluid losses while assessing integrity, healing and identifying emerging complications.

Inform patient/parent and prepare the patient. See RCH Nursing Guideline: procedure management.

Perform hand hygiene, and onto a clean trolley or work surface

Prepare equipment:

• non-sterile gloves
• dressing pack
• warmed sterile saline
• Jelonet® cut to stoma size with clean scissors if required
• gauze pack x 2
• combine pack x 1-2
• large and small clean cotton tips
• bluey to place under patient
• Orabase®
• Stomahesive®
• Barrier Cream

Dressing change:

1. Perform Hand Hygiene
2. For preterm neonate /infant pre-weigh gauze, Jelonet ® and combine and document weight on dressing for later deduction from weight.
3. Pre-squeeze Orabase® and barrier cream onto dressing tray.
4. Perform Hand Hygiene. Use gloves where appropriate e.g. remove dressings, remove gloves and perform hand hygiene.
5. Gently cleanse stoma and surrounding skin using warmed saline and gauze.  Allow to dry.
6. Old Orabase® does not need to be removed.  It can continue to protect the skin.  Assess stoma properties and skin integrity. 
7. Surround the muco-cutaneous junction thickly in orabase® using small cotton tips and gently apply Stomahesive powder®.
8. Smear a layer of barrier cream to the peri-stomal skin using large cotton tips.
9. Apply the small piece of Jelonet® to the stoma. Do not apply to skin or maceration will occur.
10. Place gauze pads followed by combine and secure with the nappy.
11. Remove gloves (if worn) and perform hand hygiene.
12. Clean trolley or work surface, dispose of waste and perform hand hygiene.
    

Potential complications:

Complications that may occur can involve the stoma itself, the surgical wound or the peri-stomal skin.  For ongoing assessment and handover purposes, the Rover/Spectralink device can be used to photograph the stoma and be uploaded to the Media section of the medical record with linkage to LDAs.

Feeding Intolerance

As enteral feeds are introduced, other complications may emerge, such as pre-stomal obstruction, strictures and feed intolerance for a variety of reasons that will need medical and/or surgical management.  Report to medical staff/ANUM/stomal consultant episodes of vomiting and changes in output volumes or appearance.  Blood in the effluent is never normal and must be investigated urgently.

Signs and symptoms of feeding intolerance include increasing gastric residuals, emesis, abdominal distension, visible loops of bowel, altered stool characteristics

High loss stoma

Neonates with stomal losses require frequent and regular evaluation of their fluid and electrolyte status to prevent complications. Refer to 'Replacement of neonatal gastrointestinal losses' NICU department guide for further information. 

Patients outside the NICU who experience high stomal losses may also need fluid replacement, this should be administered as per the medical team and should include regular monitoring of fluid and electrolyte monitoring. 

Education/discharge planning

It is appropriate that parents/carers are educated on the basic care requirements and identification of stoma complications as often parents are willing and able to attend to the stoma care needs of their child while they are inpatients.  
Adolescents are encouraged to learn how to care for the stoma and change the appliance independently.

Infants and children may benefit from medical play and distraction provided by child life therapy and/or comfort kids, refer as appropriate. 

Stoma education may begin as soon as the child/adolescent and parents/carers are willing to begin.  However, it is important to note that not all adolescents or parents/carers are willing to participate immediately and will require support to build confidence. 

Adolescents and parents/carers of child who are being discharged with a stoma will be required to learn to care for the stoma before discharge.  Care co-ordination and stoma support services are available for any child going home with a stoma. 

Special considerations 

Stoma refeeding

Occasionally a child may be ordered a stoma refeeding regime, this should always be medically/surgically initiated please see this link for further information.

Please click here for further information regarding Stoma refeeding.

Perioperative stoma care 

New Stoma bags are required to be applied to all in-patients prior to going to surgery.  

Cardiac Theatre stoma care

The patient’s stoma area will be included in a pre-op wash using 2% Chlorhexidine Gluconate wash cloth, taking care not to touch the stoma site. A Raytec® gauze (with the radio-opaque thread visible) and large Tegaderm ™ are then placed on the stoma and bag to seal the area prior to prepping. The Raytec® will be on the surgical count. The patient will then be prepped and draped as routine for Cardiac Surgery.

Images courtesy of Butterfly Unit.

General surgery stoma care
If the patient’s stoma is not being closed, but the stoma will be within the surgically draped aseptic field, hand hygiene is performed, the stoma bag removed and then a pre-wash of Chlorhexidine 0.05% and Cetrimide 0.5% applied. A Raytec® (with the radio-opaque thread visible) and a large waterproof dressing, such as a Tegaderm ™, are then placed on the stoma to seal the area prior to prepping. The Raytec® will be on the surgical count.

If the patient’s stoma is to be closed, hand hygiene is performed, the stoma bag removed and then a pre-wash of Chlorhexidine 0.05% and Cetrimide 0.5% applied.  The stoma site is left undressed.

If the patient’s stoma is not within the surgically draped aseptic field, the stoma bag may not be removed - instead left in place and draped over appropriately.

Links

RCH Policy and Procedures

• Skin and Surgical Asepsis

RCH Departmental Guideline

• Surgical Count
• Admission to Neonatal Intensive Care Unit 
• Replacement of Neonatal Gastrointestinal Losses
• Parental Nutrition in the NICU 
  

RCH Nursing Guidelines

• Neonatal and Infant Skin Care
• Neonatal Pain Assessment
• Nursing Assessment
• Routine Post Anaesthetic Observations
• Wound Assessment and Management

Evidence Table

View the evidence table for this guideline here. 

Please remember to read the disclaimer

The development of this nursing guideline was coordinated by Ret Pinnuck, Stomal Therapy/Continence CNC, and approved by the Nursing Clinical Effectiveness Committee. Updated March 2023.