OPAL AGED CARE GRADUATE NURSE

PROGRAM

STOMA MANAGEMENT

Prepared & presented by J. Martin

RN, RM, MCE (currently completing,DipAppSci, BN,
GradDipCommNsg,GradDipMid,GradCertWoundMgt,GradCertAgedCare,TAE40116CertIVTraining&
Assess, TAELLN411LLN. Feb 2020
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Learning outcomes

• Increase understanding of the definition of stoma

• Increase knowledge of types of stoma’s

• Skills & knowledge in management of stoma’s

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What does ‘ostomy’ mean

• A surgical opening into organ or part

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Formation of stoma

• Temporary or permanent

• Surgically formed by bringing a segment of small or large bowel out

onto surface of abdomen

• Excretion of faeces or urine (urostomy)

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Various types of ostomies

• Colostomy,
– can be temporary or permanent

• Sigmoidostomy

• Transverse colostomy
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• Loop colostomy

• Ascending colostomy

• Ileostomy

• Urostomy
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Stoma

• No sphincter

• Red & moist

• Not painful

• Bleed easily
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Transverse colostomy

Loop Colostomy https://emedicine.medscape.com/article/1892803-technique

Urostomy

Ileal conduit https://www.mayoclinic.org/tests-procedures/cystectomy/multimedia/img-20321246

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Urostomy
• Diversion of urine

• Most common is ileal conduit

Due to;
• Ca
• Spinal cord injury
• Chronic infection
• Birth defects e.g. spina bifida
• Cystectomy
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Psychological Issues
Ø Major surgery & prognosis

Ø Anxiety & depression

Ø QoL impacted

Ø Appliances can impact of body image

Ø Relationships may suffer

Ø Many adjust

Ø Financial impact
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Skin care
• Meticulous peristomal skin care is imperative

Causes of skin breakdown

• Faecal enzyme contact

• Moisture
• Chemical / biological irritants
• Ill fitting appliances
• Increase output
• Poorly sited stoma
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Nursing care
• Meticulous hygiene practices for both the person & nurse e.g. hand
hygiene

• Meticulous skin care during appliance change

Comprehensive assessment
• Stoma – size & shape; measure accurately
• New stomas appear swollen, decreases in about 2 – 3 weeks
• Observe peristomal skin
• Assess drainage
• Reassure & educate person, family &/or carer in stoma care
• Assess persons emotional status & implement strategies to help
with body image & stoma
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Nursing care (cont)

• Monitor medications

• Diet

• Fluid intake

• Encourage exercise
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Problems may occur;

v Stoma necrosis

v Mucocutaneous separation

v Hypergranulation

v Chemical & mechanical damage

v Pyoderma gangrenosum

v Folliculitis

v Irritant dermatitis
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Mucocutaneous separation

Pyoderma gangrenosum
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Problems may occur (cont);

v Candida

v Psoriasis

Hunter & Miller 2016

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Hydrocolloid flanges & products

v Product that absorbs exudate

v Gel forms & provides moist wound environment

v Water repellent

v Conforms to body surfaces

v Reduces pain

v Autolysis debridement
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v Range of sizes (good assessment required)

v Reduction in frequency of dressing changes – depends on exudate

Other products
Ø Sting free adhesive remover

Ø Adhesive remover wipes

Ø Barrier film wipes

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• Protective powder

• Flange extenders

• Lubricating deodorants

• Night drainage bags

• Deodorants
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Pouch type Advantages Disadvantages

Closed end pouch • Suitable for formed motions & liquid • Difficult to empty before being disposed
output of
• Change 3 x day • Changes can occur whilst away from
home

Drainable end pouch • Less frequency of changing
• Easy to empty prior to being disposed of
• Due to consistency of motion being
thicker can be difficult to empty
• Outlet needs cleaning
• Fastening mechanism can be
uncomfortable

One piece system • More flexible than 2 piece system • Requires accurate positioning
• More secure on scarred or uneven skin • Constant changing can lead to skin being
irritated

Two piece system • Base plate lasts longer, therefore gentler • Difficulty in keeping flange clean
on skin • Potential for leakage behind flange not
• Stoma can be visualized whist fitting being seen can lead to skin issues
baseplate • More bulky than one pieces system
• Clicking bag to base plate can be difficult

Adapted from the Australian Council of Stoma Association Inc

 Drainable end pouch

Closed end pouch

Closure clip

Baseplate / flange
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TRACHEOSTOMY
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Tracheostomy

What is a tracheostomy?

• ‘An opening into trachea through the neck’ (Berman et al 2018 p 1447)

• Tube inserted into trachea creating an artificial airway

https://www.mayoclinic.org/tests-procedures/tracheostomy/about/pac-20384673
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Purpose
• Maintain airway due to certain medical conditions

• Paralysis

• Surgical prep for head & neck

• Severe trauma

• Emergency situations
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Types of tracheostomy tubes

• Cuffed

• Un-cuffed

• Fenestrated

• Single cannula

• Double cannula
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• Tracheostomy tubes
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Inflamed stoma

https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0005/181454/ACI_Tracheostomy_CPG.pdf
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Tracheostomy tube care
• Assess

• Size of tube

• Cuff – is it inflated or deflated

• Check ties that secure tracheostomy

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Nursing care of tracheostomy – ALWAYS 2 staff
• Maintain airway

• Cleanliness & prevention of infection

• Assist in healing process

• Prevent skin excoriation

• Promote comfort
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Nursing care
• Assess respiratory status

• Pulse rate

• Character & amount of secretion

• Drainage on tapes or dressing

• Inspect incision (stoma)

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• PERCUTANEOUS
ENDOSCOPIC
GASTROSTOMY
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Percutaneous endoscopic gastrostomy (PEG) tubes

What is a PEG tube?

• Feeding tube inserted through the abdominal wall into stomach

https://www.asge.org/home/for-patients/patient-information/understanding-peg
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Why a PEG maybe considered

• Neurological impairment

• Head & neck cancer

• Chronic oesphageal obstruction

• Increase metabolic needs

• Congenital abnormalities

• Disorders of GIT
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Used for

• Nutrition
• Fluids
• Medications

Directly into stomach bypassing mouth & oesphagus

https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0017/251063/gastrostomy_guide
-web.pdf
https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0017/251063/gastrostomy_guide-
web.pdf
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Health professionals involved in supporting resident
• RN’s
• EN’s (under supervision of RN’s)
• Dietician
• Speech Pathologist
• Pharmacist
• GP
• Specialist
• Clinical Nurse Specialist / Clinical Nurse Consultants
• Nurse Practitioners
• Clinical Nurse Educator
https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0017/251063/gastrostomy_guide-web.pdf
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Common problems
• Occlusion

• Tube migration

• Accidental removal

• Bleeding

• Redness

• Diarrohea

• Granulation

• Hypoglycaemia
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PEG care

• Initially a dressing will surround tube insertion site, usually removed

after around 3 days

• Clean site daily using mild soap & water

• Keep dry insertion site clean & dry

• Rotate tube completely each day

• No dressing under flange unless instructed by medical officer

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• Positioning of resident for feeding
– by pump or gravity

• Flushing of tube pre / post feed (water)

• Meticulous oral hygiene is required

• Comprehensive documentation
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Observe for;
• Leakage

• Redness, pain, swelling, bleeding

• Abdominal distention

• If PEG falls out

References & Images
• ACI NSW Agency for Clinical Innovation A Clinician’s Guide: Caring for people with gastrostomy tubes & devices
https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0017/251063/gastrostomy_guide-web.pdf <16/2/20>

• Australian Association of Stomal Therapy Nurses https://www.stomaltherapy.com/ <viewed 15/2/20>

• American Society for Gastrointestinal Endoscopy (image) https://www.asge.org/home/for-patients/patient-

information/understanding-peg <viewed 16/2/20>

• Berman, A., Snyder, S. J., Frandsen, G., Levett-Jones, T., Dwyer, T., Hales, M., Harvery, N., Moxham, L.,
Langtree, T., Parker, B., Reid-Searl, K., Stanley, D. 2018 Kozier and Erb’s Fundamentals of Nursing; Concepts,
Process and Practice Volume 3. 4th ed. Pearson. Melbourne. Australia.

• Coloplast Academy (image) https://www.coloplast.us/Global/US/Coloplast%20Academy/Mucuocutaneous.pdf

<viewed 16/2/20>

• International Ostomy Association www.ostomyinternational.org/ostomy.html <viewed 16/2/20>

 References & Images
• Mayo Clinic Ileal conduit https://www.mayoclinic.org/tests-procedures/cystectomy/multimedia/img-20321246
<viewed 16/2/20>

• Mayo Clinic Tracheostomy (image) https://www.mayoclinic.org/tests-procedures/tracheostomy/about/pac-

20384673 <viewed 16/2/20>

• NSW Agency for Clinical Innovation (ACI) image

https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0005/181454/ACI_Tracheostomy_CPG.pdf <viewed
16/2/20>
• NSW Agency for Clinical Innovations (ACI) image
https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0017/251063/gastrostomy_guide-web.pdf <viewed
16/2/20>

• The Australian Council of Stoma Associations Inc (image) https://australianstoma.com.au/about-stoma/stoma-

product-guide/ <viewed 16/2/20>

• Tracheostomy.org.au (image) http://www.tracheostomy.org.uk/storage/files/Tube%20types.pdf <viewed 16/2/20>

• Koutoukidis, G., Stainton, K. & Hughson, J. 2013 Tabbner’s Nursing Care; Theory and Practice. 6th ed. Churchill
Livingstone. Elsevier. Australian

• Vijayasekaran, A. 2019 Loop Colostomy. Medscape https://emedicine.medscape.com/article/1892803-

overview#a2 <viewed 16/2/20>

• Zator Estes, M.E., Calleja, P, Theobald, K., Harvey, T. 2016 Health Assessment and Physical Examination 2nd ed.
Cengage Learning. Melbourne. Australia Hunter, S. and C Miller 2016 Nursing for Wellness in Older Adults 2nd ed.
Wolters Kluwer. Philadelphia.