STOMA

MANAGEMENT

D.UDENA ATHULA KUMARA

UNIVERSITY SURGICAL UNIT

COLOMBO SOUTH TEACHING HOSPITAL

NO OSTOMATE SHOULD SUFFER IN

SRI LANKA

HISTORY Nature induced

First stoma surgery was performed by Dr. Alex Litter in 1710 – For a six days infant

The first successful ileostomy performed by Dr.Duret in1783.

First transverse colostomy was performed by prof. Fine in1797.

First everted ileostomy was performed by Dr.Brook England in 1952.

First urostomy was performed in 1954.

First continent pouch for a ileostomy was constructed by Prof Kock Sweden.

First Enterostomal therapist is Norma N Gill … in1958.

What is STOMA ?

STOMA Greek meaning of mouth or orifice

CUTANIOUS STOMA Orifice to the surface of the skin

OSTOMY -Man made stoma.

Ostomy is the result of an operation with the aim of

removing the cause of the disease or reliving the its

sequel.

Stoma - to feed

Jejunostomy

Gastrostomy

STOMA Classification

COLOSTOMY

ILEOSTOMY

UROSTOMY

COLOSTOMY

COLOSTOMY is a surgically created opening in to the

colon-through the abdomen.The purpose of a

colostomy is to allow stool to bypass a diseased or

damaged part of the colon

INDICATIONS FOR COLOSTOMY

CONGENITAL - Ano rectal malformation

ACCQUIRD - Post radiation fistula/stricture

TRAUMATIC - Stab/gun shot injury

INFECTIVE - Diverticulitis

NEOPLASTIC - Cancer/colon/rectum

OTHER POSSIBLE CAUSES

Volvulus

Severe fecal impaction

Bowel ischemia

High anal fistula

Impairment of circulation due to CV disease

Intestinal obstruction

COLOSTOMY MAY BE

Temporary

or

Permanent at any level with in the colon

SITES OF COLOSTOMY

Caecostomy

Ascending colostomy

Transverse colostomy

Descending colostomy

Sigmoid colostomy

ASCENDING COLOSTOMY

TRANSVERSE COLOSTOMY

DESCENDING COLOSTOMY

SIGMOID COLOSTOMY

TYPES OF COLOSTOMIES

End Colostomy

Loop colostomy

Double barrel colostomy

Divided colostomy

END COLOSTOMY

LOOP COLOSTOMY

DOUBLE BARREL COLOSTOMY

DIVIDED COLOSTOMY

SMALL BOWEL OSTOMY

Jejunostomy

Ileostomy

Continent ileostomy

Incontinent ileostomy

JEJUNOSTOMY

It is uncommon.Jejunostomy is seldom seen.

It may lead to short bowel syndrome. Group of problem due

to half or more of their small bowel has been removed.

SYMPTOMES

Diarrhea, cramping,bloting of heartburn, life threatening

dehydration, malnutrition

ILEOSTOMY

TYPES OF ILEOSTOMIES

End ileostomy

Loop ileostomy

Double barrel ileostomy

Divided ileostomy

ILEOSTOMY

An ileostomy is a surgically created opening in to the small

intestine / ileum.

INDICATIONS

As a covering stoma.

I B D –Ulcerative colitis/ Crohn’s disease.

Familial Poliposis Coli

Synchronous colonic obstruction

Ischemic colitis

Amoebic colitis

Multiple colonic trauma

PAEDIATRIC –Hirschprung disease, Colonic

atresia,Meconium ileus.

Normal stoma output- 500-800 mls daily

Liquid to semi formed. Flatus + less

Ph – alkaline, corrosive.++

High stoma out put

Greater than 1000mls daily

Watery diarrhoea,

Ph alkaline-corrosive +++

COMPLICATION…Sodium water depletion

MONITOR…Electrolytes imbalance and dehydration

ROLE OF AN ENTEROSTOMAL THERAPIST/STOMA NURSE

AND

PREPARE A PATIENT FOR SURGERY.

ROLE OF AN ENTEROSTOMAL THERAPIST

The ET play an important role in the management of patient

with….

Ostomies, wounds, fistulas and incontinence care.

It is a team work

The ET plays an important role in the guidance of optimum

Care through skilled teaching, empathy and Communication

with five phases of ostomy rehabilitation.

FIVE PHASES OF

REHABILITATION

1. Pre – op phase

2. Crisis phase

3. Recuperative phase

4. Transition phase

5. Post-hosp phase

Pre – op phase

Common reaction to surgery….

Denial

Shock

Anger

Grief

Anxiety

Depression

Objectives…

1. Decrease anxiety

2. Decrease hospital stay

3. Decrease complication

4. Increase co-operation and trust

Consider…

1. General aspect

2. Physiological

3. Psychological aspects

4. Legal aspects

Crisis phase.. Increase trust and reduce fear

Recuperative Phase

Teach him/her for self care and help him to over

come his problems

Transition Phase

Develop skills in self care and knowledge of

appliances and application problems he may face.

Post hospital phase

Physical recovery

Perfect self care

Resume usual social role

OSTOMIES AND ABSORPTION

Ascending and transverse colostomies drasticaly reduse

Large amount of water and electrolytes.

JEJUNUM

Primary site of absorption of amino acids,sugar,minerals

Glycerol, fatty acid and vitamin

Site of absorption of triglycerides fatty acid and

Fat-soluble vitamins.

TERMINAL ILEUM

Site of absorption of VITB12,and bile salts.

PATIENTS WITH ILEOSTOMY

Diet pattern Eat moderately in relaxed atmosphere.

Small meals can be helpful

Avoid food causing obstruction

Course whole grain food.

Shell fishes Crabs,lobsters,prawns.

Pop corns, cracked wheat, corn and dried beans.

Membranes fruit like orange, graphs est.

Excessive diarrhea may result in dehydration.

fluids which contain electrolytes like rice, kanji

king coconut water can be taken.

Tough skins –apple, baked potato

Coarse cellulose foods- pineapple, raw cabbage

HELPFUL HINTS.

• Don’t be afraid to try new food . If there is no history

Chew food well.

• Some food may change the colour of the drainage do not get

Alarmed. After 48hrs if colour persists inform

• Be caution about fibrous vegs and tough meets and also

grains

• Be sure to drink enough fluid.

• Change in weight can cause change in stoma.

PATIENT WITH COLOSTOMY-

PRECAUTIONS

1. Chewing food thoroughly

2. Add new food gradually

3. Take precaution while eating high fibrous or cellulous foods.

4. Food likely to cause diarrhea

5. Food causing prior to operation can still be a troublesome

6. Problems of constipation taken care of

7. Balance palatable diet is recommended

8. Large amount of fluids and electrolyte needed- if

ascending or transverse col-is done.

10. Consider specific food in tolerance.

9. Small frequent diets are more beneficial.

COUNCELLING

AND

STOMA MARKING

COUNCELLING AND STOMA MARKING

It is helping some one explore a problem so they can decide

what to do about it. Enable the patient to elicit the possible

solution to his problems and select the most suitable alternative.

To Facilitate the effective counseling the nurse should endeavor

to

Be genuine and natural

Creative a conducive environment

Indicate that nurse has time

Show respect and build trust

Establish a rapport with the patient

Listen actively

Give feed back to the patient

Clarify what has been said and meaning of the word

Give encouragement

STAGE -1

CONSIDER

Patient eye sight

Patients occupation.

Hobbies and interest

Patients preference with regard to style of clothing

Dose the patient depend on any type of prosthesis?

What physical activities do the patient have?

Other particular activities .

Patients compliance regarding the stoma site.

Culture of the patient .

STAGE-2 Establish the abdomen and establish physique

Anatomical features to identify.

STAGE-3 Choosing a provisional site

STAGE-4

Evaluation of site.

STAGE-5

Making the stoma site.

COLOSTOMY SITING

Lie, Stand and sit patient

AVOID

Lower costal margins

Anterior iliac crests

Pubis

Obvious creases

Waist line

Old scars

Incision

Umbilicus

MAKE CHOSEN SITE CLEARLY WITH INDELIBLE SKIN

PEN.

Choosing the stoma site

STOMA SITES

STOMA MARKING

MOST SUITABLE STOMA SITE

MOST SUITABLE STOMA SITE

COMPLICATIONS OF A STOMA

COMPLICATIONS OF STOMA

Early Complication

Immediate post of observe for

Hemorrhage

Ischemia

• Partial ischemia

• Total ischemia

Leakage in to peritoneum

Obstructions

Fistulas

Late complications

1.Skin complications

.Caput medusa

.Allergic dermatitis

.Irritant dermatitis

.Folliculitis

.Pseudo varicose vein / Epidermal hyperplasia

.Bacterial infections

.Fungal infections

2 .Small bowel obstruction

Retraction

Vericis

Prolapse

Stenosis

Para stomal hernia

THANK YOU

COLOSTOMY

IRRIGATION

IRRIGATION TECHNIQUE

It is a procedure for cleansing the bowel by instilling fluid via

stoma

REASON FOR CARRY OUT IRRIGATION TECHNIQUE

Regain faecal continance

Cleasing the bowel prior to procedure

Eg…. Surgery X ray

Empty the bowel of faeces

Empty the bowel of faeses that causjnv a Problem

Eg….Obstru

Advantages

Patient regain the continence

No need to wear a colostomy pouch

Does not have the problem of disposing of soiled

Pouches.

Diet can be more varied with few limitation.

More economical

Patents have reported a better quality of life.

Suitable method of management for patients in hot

climate.

Disadvantages

Procedure is time consuming and takes 45 min

approximately

May find difficult to find un interrupted time in the

bathroom.

It may be difficulty when away from home.

In long term can cause bowel stasis with

impairment of natural evacuation

It may be unable to continue in old age.

Slight risk of bowel perforation.

CONTRA INDICATIONS

Patient with transverse colostomy when there is a

fluid

motion

Patient with tendency to diarrhea.

Disease of the remaining colon.

Ex.chrons ,IBD,

Caution with patient who have cardiac or renal

diseases.

Patient with stoma complication.

Patient with physically and mentally illness

Patient with lack of interest and motivation.

This procedure would not be contraindicated and

permission should be sought out from surgeon.

TEACHING THE PATIENT

Procedure should be demonstrated to the

patient and observe for one week.

Explain each and every stage clearly and

obtain feed back

After the procedure need to wear a stoma

cap or piece of lubricated gauze.

DEMONSTRATION

POSSIBLE PROBLEMS DURING

PROCEDURE

The fluid will not run in to the bowel

The water is slow to return

Abdominal cramps

Bowel acting during the procedure

THANK YOU