Postoperative stoma assessment and pouching


Selecting the proper pouching system will be influenced by the patient's size, activity level, stoma size and level of protrusion, proximity to other abdominal medical devices, and amount and consistency of effluent.

These factors will help or hinder the adherence of the skin barrier to the abdominal surface. A pouch that is properly selected will ideally adhere for predictable time intervals. A secure pouching system may also facilitate positive parental adaptation to the change in body image and function of their child.

STOMA ASSESSMENT

  1. Anatomic location of diversion and stoma type- note where stoma diversion in gastrointestinal (GI) or genitourinary (GU) tract diversion is located.
  2. Stoma viability- the stoma should be moist and bright red. A stoma does not have nerve endings to transmit pain. It is vascular and may bleed slightly when rubbed or irritated-this is normal.
  3. Height of the stoma- a stoma can be at skin level, retracted (below skin level), or prolapsed (telescoped out) from the abdominal surface. The degree to which a stoma protrudes from the abdominal surface often will give an indication of how well a pouch may adhere to the abdominal surface. The ideal stoma should protrude slightly, being 1 to 2 cm above skin level. This makes it easier to obtain a secure seal of the pouching system, whereas a skin level or below skin level stoma can make it challenging to maintain pouch adhesion, especially if the peristomal skin surface has any uneven contours such as the umbilicus or suture lines. When effluent exits at or below skin level, it is much more likely to go underneath the skin barrier, which often results in skin irritation and leakage. A stoma that is prolapsed is more at risk for trauma from the pouching system, nappy, or closure. Furthermore, many parents and older children find these prolapsed stomas quite upsetting to see because there is so much bowel sticking out of their body. Adaptation to pouching techniques may need to be made for skin-level, retracted, or prolapsed stomas.
  4. Location of the opening where effluent empties from the stoma-ideally effluent empties from the top of the stoma as opposed to "the spout being tipped" down toward skin level. It may be more challenging to maintain a secure skin barrier adherence when effluent exits directly at skin level. Adaptation to pouching techniques may need to be made. It is helpful to document this location in reference to the hands of a clock (ie, exiting at 1:00 o'clock).
  5. Abdominal location-ideally, the stoma is placed away from the umbilical cord in newborns, below the belt line in older children, and away from groin folds, incisions, or old scars to allow adequate surface area for the stoma care appliance to adhere. A stoma placed in any of these areas can make pouching adherence more challenging because of hip movement or an uneven peristomal skin surface.

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