|Year : 2022 | Volume
| Issue : 1 | Page : 3-7
Home management of intestinal stoma: An evidence based review
Harmeet Kaur Kang1, Mamta Choudhary2
1 Principal, College of Nursing, Chitkara School of Health Sciences, Chitkara University, Patiala, Punjab, India
2 Faculty, College of Nursing, AIIMS, New Delhi, India
|Date of Submission||25-Jun-2021|
|Date of Decision||20-Sep-2021|
|Date of Acceptance||22-Sep-2021|
|Date of Web Publication||24-Mar-2022|
Ms. Mamta Choudhary
College of Nursing, AIIMS, New Delhi
Source of Support: None, Conflict of Interest: None
Shortened hospital stays for clients with an intestinal stoma have shifted the focus from institutional care in hospitals to self-care of ostomies to the home setting. Clients with intestinal ostomy experience numerous changes in physical functioning, psychosocial health, and in their sexual life after creation of stoma. This enhances the importance of a guide for home management of intestinal stoma to assist home care clinicians and stoma care nurses, who are determined to make ostomates self-reliant. This evidence-based review focused on published articles from the Medline, CINAHL, Social Sciences Citation Index, Psych INFO, a hand search through selected journals published since 2000, and from references lists, to prepare home management guide for intestinal stoma. This article provides information regarding measures to protect skin around stoma, daily care management for ostomates, and ways to prevent peristomal skin complications.
Keywords: Colostomy, home management of stoma ileostomy, stoma care, stoma complications
|How to cite this article:|
Kang HK, Choudhary M. Home management of intestinal stoma: An evidence based review. J Appl Sci Clin Pract 2022;3:3-7
|How to cite this URL:|
Kang HK, Choudhary M. Home management of intestinal stoma: An evidence based review. J Appl Sci Clin Pract [serial online] 2022 [cited 2022 May 17];3:3-7. Available from: http://www.jascp.com/text.asp?2022/3/1/3/340877
| Introduction|| |
One well-known form of an artificial stoma is an intestinal ostomy, i.e. colostomy or ileostomy, that is, a surgically created opening in the colon or ileum respectively. On an average, yearly estimates of ostomy surgeries in India vary from 42,000 to 65,000 (World Laparoscopic Hospital, Delhi). Stoma creation puts an immense impact on gastrointestinal functions, as well as on psychosocial health, sexual life, body image, and finances., The ostomates, especially those living with permanent ostomy, require life-long specialized nursing care to adapt to these changes. However, as it is not feasible for every person with stoma to have an access to ostomy nurse specialist, it leads to an increased risk of maladjustment to the changing life situations further worsening quality of life. Therefore, the development of ability for self-care and home management of colostomy/ileostomy is a vital component of a holistic approach of optimal management of these clients. These guidelines can assist primary care physicians to ensure that stoma patients maintain a good quality of life with their stoma and prevent avoidable complications to a maximum extent.
| Methodology|| |
Identifying the published papers for inclusion and determination of their relevance
This evidence-based review focused on published articles from the Medline, CINAHL, Social Sciences Citation Index, PsychINFO, a hand search through selected journals published since 2000, and from references lists, to prepare home management guide for intestinal stoma that can help stoma care nurses to make ostomates self-reliant. The suitability of the articles for inclusion was determined by the following screening questions: (1) Is the article published in authenticated peer-reviewed journals? Articles published in journals that lacked the authentication of legitimate scholarly journals such as peer review, editing, editorial boards, editorial offices, and other editorial standards were excluded from the review. (2) Is the focus of the paper relevant to the review topic?
Quality appraisal of included articles:
Two main criteria were used in the evaluation and quality appraisal of included articles, i.e. credibility and relevance. Screening questions used to further scrutinize the articles on the basis of credibility and relevance were:
- Did the articles mentioned management of common alterations related to the intestinal ostomy such as constipation, intestinal gases, daily routine management of stoma, changes in physical activities, difficulties with work routine and traveling, sexual issues, social isolation, nutritional issues, ostomy irrigation, and alteration in psychological health
- Has the article mentioned scientific evidence for management guidelines of common alterations related to intestinal ostomy?
- Did the authors acknowledge the influence of the research process and the presence of researcher including the role of prior biases, assumptions, and experience, on the collected data?
- Is the article published in authenticated peer-reviewed journals?
| Results|| |
A total of 27 studies based on inclusion–exclusion criteria and quality appraisal were included in the review. Condensing labels were used to summarize and list down the perspectives of various studies. Labels identified by researchers were noted and cross-checked against their cited data. After summarization of data in each paper by labels, these were charted under unifying headings to establish guidelines for home management of intestinal stoma.
Home management of intestinal stoma
Stoma care nurses can train ostomates to manage their stoma and perform independent care of stoma in the home settings. The following points should be considered while teaching self-reliance to ostomates:
Protecting the skin around stoma
The skin around the stoma can become tender or swollen because of ostomy output and stoma appliances. The skin can be kept healthy by using the following tips:
- Use stoma pouch with the correct size of opening: Stoma pouch opening size should be cut as per the size of stoma. Small opening can injure or cut the stoma and may lead to swelling; however, output from a large opening can irritate the surrounding skin. Thus, using correct size opening is of utmost importance for the health of stoma
- Change the stoma pouch regularly: It helps to prevent leakage from the stoma and avoid skin irritation. It should be changed as per the manufacturer's instructions without waiting for itching, burning, leaks, or other addition problems
- Skin around the stoma should be washed with warm water. Attach the pouch once the skin is completely dry. Avoid alcohol-containing products to prevent over-dryness of the skin. Prohibit use of products that contain oil as it makes adhesion of pouch to the skin difficult,
- Monitor for allergies and sensitivities to the adhesives, tape or pouch material, skin barrier, paste, etc., and report to the physician if these occur.,
Daily care management
Minor alterations in clothing patterns can enhance comfort among ostomates. Irritation and injury to stoma can be prevented by avoiding tight belts directly over the stoma. Waistbands should be worn above or below the stoma to promote convenience. Stoma guards can be used to safeguard stoma from injury that may result from contact sports, seat belts, or from other similar contacts.
Stoma pouches are not visible through clothing if emptied when they are one-third full. Specialized pouches with soft absorbent fabric can enhance ease of ostomates. Specially designed undergarment for stoma patients can cover and support the stoma pouch and thus can be used to promote comfort.,
Bathing is one of the biggest concerns for people living with an ostomy. However, routine exposure to air, water, and soap neither harms the stoma nor hampers adhesion feature of stoma pouches. The stoma pouches can be easily worn while opting for underwater swimming or bathroom showers, as adhesive power of pouches will remain intact. One should dry skin thoroughly after bathing or showering and should use handheld hair drier to trigger wafer adhesive for a tight seal. Hair dryer should be used at lowest (cool) setting, with air flow directed toward the edges of the adhesive ring of the pouch. It is advisable to keep hair dryer at a distance of at least 6 inches away from the stoma and use it for 5 min or less. Avoid using the dryer if skin is red or sores are present.,,
Exercise and sports
The activities need to be restricted for a short period after surgery to allow the body to heal. However, Wiskemann et al. concluded in a study that it is possible for ostomy clients to regain fitness for physically demanding tasks through an individually tailored and supervised training program. The general guidelines that need to be followed after stoma creation include:
- Avoid driving, at least for 3 weeks after surgery. Abstain from lifting heavy weight (10 lbs. or more) for a period of 6 weeks postsurgery
- Consult the doctor before resuming exercise routine. Avoid participating in contact sports such as basketball, football, wrestling, etc., as it may enhance the risk of injury to the stoma
- Weight lifting can cause hernia, thus consult a physician before initiating it.
Always carry extra supplies, while going for a journey. Stoma supplies should be arranged in carry-on luggage rather than with checked-in luggage when opting for flights for traveling. If traveling by car, try to avoid trunk and back window ledge for keeping stoma supplies, rather identify some cool places in car and store supplies there. If long outings are planned, amount and safety of supplies should be arranged accordingly.,
Majority of patients with stoma experience sexual problems and worry about their intimate relationships postostomy creation. However, ostomy creation cannot decrease or manipulate a person's potential to love and care for others and establish an intimate bond with another person. Furthermore, stoma, once healed, is not harmed by sexual activity and hugging. It is necessary to express feelings toward partner, show affection, talk to them, and to listen and understand their concerns toward stoma to establish a healthy relationship. Planning of birth control by women of childbearing age with a stoma can help the body to heal post surgery. Few points to be kept in mind when engaging in sexual activities are:,
- Always empty the pouch before initiating sexual activity. Fold up the emptied pouch and secure it with tape or cotton cover to avoid it from flapping around
- Wear apparel that are comfortable
- Consider using an ostomy wrap with an inner pocket. The wrap helps to conceal the pouch, thus can boost confidence related to appearance
- Smaller pouch or caps can be used for the occasion of sexual activity.
Vanessa Cristina Mauricio et al. reported dialectical feelings among colostomy clients in relation to the work, considering that work activity is a source of life, ensures material subsistence, and signifies social participation. However, they also consider the work as a source of suffering, as they link it to a feeling of exclusion and to social segregation. One should go back to work only when he/she is feeling well and is comfortable to resume the occupational responsibilities. Consult a gastro-surgeon regarding available options before initiating a job that necessitates heavy weight lifting. Decide who among the co-worker one wants to tell about colostomy. Be comfortable and seek help where needed.,,
Nutrition plays an important role in the health and healing of clients with ostomy. The aim of nutritional management in ostomates includes prevention of stoma blockages after surgery, minimizing unpleasant gastrointestinal upset such as flatulence, diarrhea, constipation, and odors, and promotion of healing of stoma. Canned fruits and well-cooked vegetables should be preferred over fresh fruits and vegetables for few weeks following surgery. People with ostomies should consider the following points while planning their diet:,,,
- Eat meals regularly. Colostomy clients should eat three or more times a day. Skipping meals will not stop stoma output. Small and frequent meals are better tolerated and are known to produce less gas. It is also important to eat high potassium foods such as bananas, apricots, tomatoes, potatoes, squash, or drink orange juice
- Chew the food thoroughly. Chewing the food well helps to prevent obstruction in the bowel
- Eat in moderation and slowly. Eat moderate amount of food in one meal as excess can cause trouble. If any of the new food items cause discomfort, avoid it for a period of time, and give it try again later
- Drink plenty of fluid daily: Ostomates must stay hydrated as body loses more fluids through the ostomy. Increase fluid intake of at least 2 L/day or more if the stool is liquid in consistency. Electrolyte content of sports drinks makes them a preferred choice. The intake of fluid is normal if urine is clear to pale yellow in color; however, fluid intake should be increased if urine color becomes darker
- Predominantly, different people react differently to the same food items: A variety of food need to be tried to identify which food items should be avoided. [Table 1] describes food guide for ostomy clients.
Managing intestinal gas
During the early weeks and months after surgery, client may experience excessive gas. This lessens after the bowel healing and after resuming a regular diet. Eating leisurely in a relaxed atmosphere with closed mouth and proper chewing helps to prevent excessive gas. Carbonated drinks and chewing gum should be used in moderation. Avoid food that causes intestinal gas, constipation, and irregular irrigation.,
| Drug therapy|| |
Time-released and time-sustained medicines are proven to be less effective in patients with stoma, especially with ascending or transverse colostomies, as an intact intestine in for their absorption. Thus, it is advisable to inform the physician about colostomy so that treatment can be planned accordingly.
Irrigating the ostomy
Ostomy irrigation is a technique to control bowel movements by evacuating the colon at a scheduled hour. To irrigate the colon, water is infused into the colon through the stoma by using a long tubing and a cone. This process triggers the colon to get emptied. Ostomy irrigation is a way to train the colon to empty at scheduled times with no spillage in between irrigation, thus helping clients to regulate their bowel movements. Supervision of an ostomy nurse during first irrigation by the client is always recommended to learn and perform the procedure in right manner. Irrigation can be started after completion of healing process postsurgery.,
On an average irrigation, the process takes 30–60 min to perform and allows ostomates to remain free of stool drainage for 24–48 h. The procedure if performed regularly decreases the need of ostomy equipment and thus the cost related to these. It is advisable to irrigate the colon at the same time every day using lukewarm water. In case of abdominal cramping, stop infusion of water, massage the abdomen, and retry after a while. Consult a gastro-surgeon or ostomy nurse if cramping persists.,
Managing peristomal skin complications
| Allergic contact peristomal dermatitis|| |
This is an inflammatory or allergic skin reaction to acrylic or resin components of the stoma appliance such as pouching system, adhesive tapes, etc., It generally affects areas in contact with stoma appliances.,,
- Identify the allergen and avoid using identified irritants or allergens
- If allergic reaction is because of pouching system, opt for another pouching system with different chemical composition
- Crusting technique can help in case of denuded skin. It includes using ostomy powder and skin preparations such as skin sealant or barrier films covering the ostomy powder layer, to form a crust on the affected peristomal skin,,
- Consult a dermatologist in case of moderate-to-severe allergic reaction. It is advisable to use topical steroid spray rather than steroid creams, as creams can interfere with adhesive properties of the pouching system.,,
It is an inflammation or infection in hair follicles around the peristomal skin., Causative factors may include occlusion of the follicle from occlusive ointments; tight clothing; trauma from rubbing/friction; multidirectional or aggressive shaving; and/or chronic pulling of the hair during removal of an adhesive pouching system, followed by the secondary infection.,,
- Trim the peristomal hair at regular intervals
- It is safe to use an electric razor or hair clipper. Trimming in the direction of hair growth can help to avoid razor bumps
- Dry shaving, close shaving, and/or frequent shaving should be avoided to prevent shaving irritation,
- Apply, moisturizer, preferably alcohol free, after shaving. The skin should be thoroughly washed and dried before applying a new pouching system,,,
- Gently remove flange of pouching system by pulling it toward the stoma, and supporting the surrounding using other hand. Cleanse the skin with antibacterial soap
- Consult a dermatologist or ostomy care nurse in case of severe inflammation. Prescribed topical antibiotic powder can help to ease the inflammation.,,
Mechanical trauma to the peristomal skin and/or underlying tissue mostly presents as pressure ulcers secondary to pressure caused by the external pouching system.
- Mechanical Injury can be avoided by preventing pressure to the peristomal skin. It can be achieved by ensuring proper fit of the pouching system and periodically examining the peristomal skin for signs of pressure,
- If belt/binder is needed, a wider belt/binder should be opted ensuring they are not tight on the skin,,
- ”Crusting” technique should be used in case of superficial, partial-thickness ulcers. Medicated powder can be used as skin barrier to the ulcer each time before applying new pouching system until the ulcer is healed,,
- Consult a dermatologist in case of deeper, full-thickness ulcers. Consider aseptic dressing that should not interfere with the adhesion of the pouching system along with a nutritious diet to enhance healing process.,,
Medical adhesive-related skin injury
It is a type of peristomal skin injury in which epidermal cells (i.e. one or more layers of the stratum corneum) are stripped away, and/or the epidermis separates from the dermis when the adhesive portion of the pouching system or tape is removed from the skin.
- Skin sealant/barrier should be used before applying an adhesive product as it can ease in removal of the adhesive product without harming underlying skin
- Maintain adequate hydration/nutrition status,,
- Consult a skin/wound care specialist if conservative management fails to treat the skin injury.,,,
Chemical skin injury
It includes inflammatory reaction of the skin resulting from chemical compound of the topical products such as adhesives, cleansers, etc.,,
- Identify and avoid the causative factor. Replace allergens with other suitable products
- In case of denuded skin:
- Consider using skin barrier powder to the damaged skin as it can absorb moisture and provide protection ,
- Select nonadherent or absorptive dressings according to the extent of skin damage and exudate,,
- Refer to a dermatologist if the condition does not improve with conservative treatment. Topical steroids can help to ease the irritation.,,
It is common to grieve the change in self-image and deal with a sense of having an imperfect body and have feeling of loss of control. Ostomate should try to regain a sense of control, through self-care and avoiding ostomy complications. The following interventions can be used to enhance positive coping with the situation:,
- Interact with other ostomates and learn self-care in group with and from another person
- Focus on problem-solving strategies to deal with various limitations, to establish a relationship with family members and significant others
- Join ostomy support groups or spiritual or psychological counseling.
| Conclusion|| |
Intestinal Stoma is not a disease, but a change in the way the body works. It surgically changes normal body function to allow stool to pass after a disease or injury through an opening that is surgically created on the anterior abdominal wall. People with stomas can enjoy normal life and wide range of activities allowing proper communication with the society. Complications of stomas remain common, although self-stoma care can improve the overall patient outcome.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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