Which covering would the nurse use over the exposed area of an infant admitted with exstrophy of the bladder?

Note: This guideline is currently under review. 

Introduction

Aim

Definition of Terms

Assessment

Management

Special Consideration

Evidence Table

References 

Introduction

This guideline applies to all infants returning post-operatively with a stoma.

The conditions that require stoma formation include anorectal malformations, Hirschsprung disease, intestinal atresias, necrotising enterocolitis 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 syndrome.  In most situations, the stoma may be closed prior to discharge from hospital or the patient may be discharged home with the stoma in-situ.

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

Aim

• Outline initial post-operative assessment and management of the newly formed stoma.
• Provide a guide to dressing changes and bag application
• Outline management of fluid and electrolyte balance.
• Explain complications and common problems associated with stomas so that early recognition and management may be implemented.
• Outline ongoing management of the active stoma and enteral feeding introduction.
• Explain re-feeding and procedure for re-feeding.
• Provide pictorial guidance for infant’s undergoing surgery with a pre-existing stoma.

Definition of Terms

• OSTOMY: surgically formed opening from the inside of an organ to the outside.
• STOMA: the part of the ostomy that is attached to the skin.  It is constructed from the (usually) end of the bowel that has been surgically brought up through the skin and attached.
• ILEOSTOMY: a part of the small intestine is diverted out through the abdomen.  Output is liquid and may look undigested.
• COLOSTOMY: a part of the colon is diverted out through the abdomen.  Output may initially be meconium becoming yellow and curdy.
• 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.
• OROGASTRIC TUBE: small plastic tube passed through the mouth and oropharynx, down the oesophagus and into the stomach.
• NASOGASTRIC TUBE: small plastic tube passed through the nare and nasopharynx, down the oesophagus and into the stomach.
• NASOJEJUNAL TUBE: small plastic tube passed via the nose, back of the throat, down the oesophagus, stomach and through the pyloric sphincter into the jejunum.

Types of stomas

• 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.
• DOUBLE-BARRELLED: 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.
• HIGH OUTPUT STOMA – any stoma that produces equal to or >20ml/kg of effluent and required replacement of gastrointestinal losses to prevent complications.

Assessment

Physical Assessment

Most infants will return postoperatively with Jelonet and gauze over the stoma.  The laparotomy suture line should have an adhesive dressing over it which should remain intact until surgical direction to remove. 

Stoma observations should occur upon return to ward post-operatively and at least 4 hourly thereafter.

Observe

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
• Taut - oedema (oedema will subside over the coming weeks, with actual stoma size presenting towards the end of week 2)
• 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 2-3 cms

MUCOCUTANEOUS JUNCTION (where the stoma meets the skin)

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

PERISTOMAL 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 Wound Care Nursing Guideline if further information required.

Ongoing Assessment

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 can be used to photograph the stoma and be uploaded to the Media section of the medical record with linkage to LDA’s.

• Bleeding stoma – may be normal, as mucous membranes are very vascular.  Report excessive bleeding, bleeding that does not stop within a reasonable time frame or bleeding that has been caused by accidental trauma.
• Prolapsed stoma – not able to be controlled but needs to be monitored.  Document approximate length of protrusion and observe for signs of reduced perfusion, such as darkening, cooling or drying of the stoma or progressing prolapse.  Report and document the prolapse to neonatal and surgical medical teams/ANUM/stomal consultant and in the EMR.  There may be implications for stoma appliance selection once stoma is active.
• Retracted stoma – Report retraction to neonatal and surgical medical teams/ANUM/stomal consultant.  Implications regarding stomal appliance may exist.  Retracted stomas may create issues around wound and peri-stomal skin integrity as the stoma activity increases.
• Ischaemia/necrosis – an emerging medical emergency so escalate to the neonatal and surgical teams immediately for urgent surgical review and report to ANUM/stomal consultant.
• Muco-cutaneous separation – if sutures separating between stoma and skin, report to medical staff/ immediately so surgical review may occur and notify ANUM/stomal consultant  Skin integrity and wound healing differs greatly between infants.
• Wound breakdown – document wound details, including size and depth of opening, colour of surrounding skin, inflammation contours, exudate and odour.  Refer to wound Care Guideline and report to medical staff and ANUM/stomal consultant.  Dressing modifications and surgical review may be required. 
• Peri-stomal skin breakdown – at any stage in stoma management, peri-stomal breakdown may require reversion to dressings if stoma bags cannot be used due to skin integrity breakdown.  Notify medical staff/ANUM/stomal consultant if assessments include deterioration in integrity, turgor and colour of peri-stomal skin.  If required, follow the procedure for stoma dressing and change 4/24 and prn once soiled.
• High loss stoma – once feedings have begun, losses will increase.  A high loss stoma will produce >20 ml/kg of effluent in a 24-hour period and the infant will require replacement of these losses at the time they reach the 20ml/kg loss. Refer to Replacement of Neonatal G.I losses guideline.

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.

Feed Intolerance symptoms

• Increasing gastric residuals
• Emesis
• Abdominal distension
• Visible loops of bowel
• Altered stool characteristics

Stomal Therapy

Stomal therapy consultants at RCH are employed by the Department of Education and Training and receive a 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 by the surgical teams. 

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

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

Contact stomal therapy on:

Phone 3945 5338

ASCOM 52496

Investigations 

Infants with stomal losses require frequent and regular evaluation of their fluid and electrolyte status to prevent complications.  Sodium is critical to growth and infants with ongoing sodium deficits are at risk of impaired growth and cognitive dysfunction. 

Increased sodium losses are associated with high output stomas, anatomically higher stomas and premature infants.  

• Serum electrolyte/urea/creatinine: should be checked at least daily until stabilized, then weekly until re-anastomosis.  More frequent checking may be required dependent on the infant’s weight gain, stomal losses, age, electrolyte stability and general condition. 
• Urinary sodium: Should be checked weekly. The sample does not need to be sterile.  Normal ranges vary; however, urinary sodium levels should be maintained between 20-40mmol/L.  If infants have poor growth or high losses, this may need more frequent checking.  In infants with good renal tubular reabsorption, urinary sodium is the best measure of total body sodium and levels of depletion. However, results may be misleading in preterm infants and those with renal disease.  Do not rely on serum levels as evidence of total body sodium.
• Sodium supplements: In infants able to tolerate oral medication, 6% sodium (Hypersal) is the appropriate supplement.  A low urinary sodium (<20mmol/L) is the indication for commencement of supplements.  However, most neonates with a stoma will require supplementation 2-4 mmol/kg/day. An IV sidearm of Sodium 3% (or 0.9%) and modification of TPN are alternatives for infants not suitable for oral sodium supplements.
• Acid base balance: A capillary sample will be required in any unwell infant who has losses > 20 ml/kg.  There may be many other reasons a neonate requires a Capillary Acid Base sample not directly related to the stoma, for example, ventilated infants or those with sepsis.

 https://www.rch.org.au/neonatal_rch/intranet_Drug_and_electrolyte_dosing_in_the_RCH_NICU/

Management 

Patient’s returning post operatively will require 4 hourly dressing changes at a minimum, moving to 4-6 hourly PRN as assessments and stomal characteristics change.  Several products are available for use.

PRODUCT DESCRIPTION

• orabase: protective paste that may be used around the stoma to prevent breakdown or assist with healing if skin broken and weeping.
• ilex: topical occlusive skin barrier that repels moisture and bacteria.  Can adhere to moist, weeping tissue and severely excoriated skin.  This is not ward stock and should be recommended by a stomal specialist.
• jelonet: primary stoma dressing consisting of paraffin gauze that prevents secondary dressing adhering to stoma, keeps stoma moist and allows drainage.
• 1 piece appliance: wafer and bag in one appliance – default product on Butterfly is dansac wafer and bag.
• 2 piece appliance: separate wafer and bag that sticks or clips in place. (Require stomal specialist assessment before provision for permanent stomas in going home infants)
• caulking strips: moldable strips or rings to be softened in gloved hands and used to “build-up” areas of indentation, scars, defects and skin creases to increase convexity, create a barrier and decrease the likelihood of stools seeping into creases and creating loss of wafer adhesion.
• wafers: usually circular and internally cut to stoma size.  May be dansac brand with bag that attaches or if increased convexity required, use Bravia protective sheet 3210 as this is more flexible.
• stomahesive: a powder that assists in protection of muco-cutaneous junction separation, defects and weeping skin.  Forms a protective barrier to surface of stomas and assists with superficial bleeding.
• gauze: used as a secondary dressing, sterile with minor absorptive qualities.
• combine: used a tertiary dressing for added absorptive qualities.

Contact Clinical Technology to supply base products and specialized products such as 2-piece bag systems and eakin strips/caulking paste can be obtained by contacting Stomal therapy on ASCOM 52496.

DRESSING CHANGE PROCEDURE

Inactive stomas or extreme excoriation of peri-stomal skin due to bag leakage. Aim is to keep the stoma clean and moist and to measure fluid losses while assessing integrity, healing and identifying emerging complications.

See: Procedure - Inactive stoma dressing change.

See: Procedure – Active Stoma bag application procedure.

ONGOING MANAGEMENT

MANAGEMENT OF NASOGASTRIC TUBE:

A nasogastric or orogastric tube must be insitu and open to free drainage into a yellow container with an air escape hole cut into it.  Never clamp the NGT unless directed by the surgical team. When feeding commences, it will be via this tube and clamping for up to an hour post feed/medication administration then venting will be appropriate. 

Gently aspirate yellow container to form a documented loss every 4 hours until feeding commences.  Document separately as “aspirate” and “drainage” in the Fluid Balance section of the EMR Flowsheets.

PROCEDURE FOR BAG APPLICATION/CHANGE:

Introduction of enteral feeds will increase output and require skin protection with stoma wafer and bag.  Small dantac bags are used with circular wafers and are available by contacting clinical technology who will arrange supply.  However, if increased convexity is required due to scar indentations Bravia protective sheet 3210 may be cut to size.  It is hoped that initially bags can remain insitu for at least 24 hours – 72 hours to preserve skin integrity.  Never reinforce a wafer as effluent will be on the skin underneath corroding it.

You may wish to angle the new bag so it rests sideways across the abdomen and can be covered with the nappy.  Bags pointing straight down may become contaminated with urine and may adversely affect skin integrity and wafer adhesion.

If the wafer and bag are secure with no evidence of leakage, the bag can be opened from the bottom and using a syringe with white tipped aspirator, remove contents and document output in Fluid Balance every 4 hours.

NUTRITION:

Patients will require TPN until the stoma becomes active, indicating returning intestinal function.  Feeds will initially be trophic, increasing at a rate determined by medical staff.  Daily gradings should be assessed for tolerance and symptoms of feed intolerance reported to the ANUM and medical team. 

REFEEDING:

Follow link: PROCEDURE – Refeeding

The first NGT insertion into the mucous fistula is to be conducted by the surgeon or their delegate.  If documented as appropriate, suitably experienced nurses may insert subsequent tubes to the documented length.

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 infants while they are inpatients.  Stoma education may begin as soon as parents/carers are willing to begin.  However, it is important to note that not all parents are willing to participate immediately and will require support to build confidence.

Parents whose infant is 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 infant going home with a stoma.

Special Considerations

Special Considerations for Perioperative Stoma Care

New Stoma bags are required to be applied to all in-patients prior to going to surgery.  Refer to procedure for bag application change as per guideline.

Intra-operative Cardiac Theatre Stoma Care

Hand hygiene performed.

The 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 and large tegaderm are to be used to cover the stoma bag. The patient will then be prepped and draped as routine for Cardiac Surgery.

Intra-operative General Surgery Stoma Care

Hand hygiene performed.
The stoma bag will be removed prior to scrub and then a pre-op wash using Cetrimide.

If the procedure is not to close the stoma, the stoma site will be dressed with a raytec gauze and large tegaderm will be used to cover the stoma bag after the patient has been prepped and draped.

If the stoma is to be close it will remain undressed and surgery to continue.

Related Procedures

Admission to Neonatal Intensive Care Unit

Neonatal Pain Assessment

Replacement of Neonatal Gastrointestinal losses

Neonatal and Infant skin care

Routine Post Anaesthetic observations

Nursing Assessment Guideline

Wound Care

Parenteral Nutrition in the Newborn Intensive Care Unit

Drug and Electrolyte dosing in the RCH NICU

Evidence Table

The evidence table can be viewed here. 

References

• Waller, M.  (2008) Paediatric stoma care nursing in the UK and Ireland.  British Journal of Nursing.  17(17); pp S25 – S29.
• Birch, J and Sica, J.  (2007) One-and two-piece colostomy appliances: merits and indications.  British Journal of Nursing.  16(17); pp 1042 – 1047.
• Kargl, S, Wagner, O and Pumberger, W.  (2017) Ileostomy Complications in Infants less than 1500 grams – Frequent but Manageable.  Journal of Neonatal Surgery.  6(1); 4.
• Ngyen, H and Houska Lund, C.  (2007) Exploratory Laparotomy or Peritoneal Drain?  Management of Bowel Perforation in the Neonatal Intensive Care Unit.  Journal of Perinatology and neonatal Nursing.  21(1); pp 50 – 60.
• Mansout, F, Peterson, D, De Coppi, P and Eaton, S.  (2014) Effect of sodium deficiency on growth of surgical infants: a retrospective observational study.  Pediatric Surgery International.  30; 1279 – 1284.
• Butterworth, S, Lalari, V and Dheensaw, K.  (2014) Evaluation of sodium deficit in infants undergoing intestinal surgery.  Journal of Pediatric Surgery. 49(5); pp 736 – 740. Stoma Care.  Great Ormond Street Hospital.  Accessed via HYPERLINK "http://www.gosh.nhs.uk/health-professional/clinical-guidelines/stoma-care" http://www.gosh.nhs.uk/health-professional/clinical-guidelines/stoma-care.
• Yadav, P, Choudhury, S, Kumar Grover, J, Gupta, A, Chadha, R and Sigalet, D.  (2013)  Early feeding in pediatric patients following stoma closure in a resource limited environment.  Journal of Pediatric Surgery.  48; pp 977 – 982.
• Rogers, V.  (2003) Managing Premmie Stomas: More than Just the Pouch.  Journal of Wound and Ostomy Care.  30 (2); pp 100 – 110.
• Ratliff, C, Scarano, K and Donovan, A.  (2005) Descriptive Study of Peri-stomal Complications.  Journal of Wound and Ostomy Nursing.  32(1); pp 33 - 37. Kent, D.  (2008) Changing an Ostomy.  Nursing.  December.  Accessed via HYPERLINK "http://www.nursing2008.com" www.nursing2008.com.
• Hyland, J.  (2002) The Basics of Ostomies.  Gastroenterology Nursing.  25(6); pp 241 – 244. Chandler, P.  (2015) Preventing and treating peristomal skin conditions in stoma patients.  British Journal of Community Nursing.  20(8); pp 386 – 388. 
• Rhee, D, Karim, O, Weir, B, Stewart, D, Lukish, J, Lau, H, Abdullah, F, Gauda, E and Pryor, H.  (2016) Mucous fistula refeeding parenteral nutrition exposure in postsurgical premature neonates.  Journal of Pediatric Surgery.  51(11); pp 1759 – 1765. Covenant Health Enterostomy Refeeding Guideline.  Accessed at extcontent.covenanthealth.ca/Policy/Enterostomy_Refeeding.pdf

Please remember to read the disclaimer 

The development of this clinical guideline was coordinated by Jessica Smith, Clinical Nurse Educator, Butterfly Ward. Approved by the Clinical Effectiveness Committee. First published November 2018.

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