There are almost 200 000 people in the UK with a stoma (University of Birmingham, 2019). This equates to about one person in every 335. Most people with a stoma are taught in the hospital setting to undertake the care of their stoma and become independent with the care. However, some people are unable to be independent with their stoma care needs for a number of reasons, such as dementia or a fractured arm. Having a stoma can thus be difficult for some people, and this is made even more difficult if a stoma complication occurs. Complications can relate to the stoma itself, for example, it may retract. Alternatively, the complication can be related to the peristomal skin, for example, skin erosion. Community nurses are ideally placed to assist patients with their stoma care, although they will infrequently need to be involved in-depth with stoma care. Nonetheless, the community nurse needs to have a working knowledge of many aspects of healthcare, and a reminder about stomas and complications and how to manage these can be beneficial. If complications occur, however, a basic understanding of causes can often help with assessment and treatment planning.
Stomas
Stoma is a Greek word for mouth or opening, and, for the purposes of this article, only output stomas will be considered, that is, the colostomy, ileostomy and urostomy (Burch and Black, 2017). A colostomy is formed from the colon to enable the person to pass formed faeces and flatus. An ileostomy is formed from the ileum (the last part of the small bowel) and will pass loose faeces and flatus (Figure 1). A urostomy (or ileal conduit) is most commonly formed from the ileum to divert urine out of the body. A stoma is a piece of bowel that is brought through a surgical opening on the abdominal wall and then stitched to the abdominal skin. It can be formed for cancer, inflammatory bowel disease or diverticular disease, as well as for faecal or urinary incontinence. A stoma can be temporary or permanent; temporary stomas are usually in situ for several months, although this could stretch to several years if chemotherapy is needed or a complication with healing occurs, for example.
Figure 1. Example of a loop ileostomy with the aperture cut too large
In appearance, a healthy stoma will be pink or red in appearance. A colostomy should be raised about 5 mm above the skin level, ideally, and an ileostomy and urostomy should be ideally spouted with a 25 mm spout of bowel. To touch, a stoma will be moist and warm (health professionals should wear gloves when providing stoma care, as universal precautions, but this is unnecessary for patients). In appearance, the skin around the stoma should appear the same as the skin on the rest of the abdominal wall, free from discolouration, breaks and irritation (Boyles, 2010).
Stoma appliances
There are three main differences in the appearance and function of a stoma appliance (stoma pouch) related to the three main stoma types. Appliances are available in one-piece and two-piece formats. One-piece appliances have the collection part of the appliance and the adhesive part joined (Figure 2). In two-piece appliances, these two sections are separate and joined by the person applying the stoma appliance. In the UK, there is a preference for one-piece appliances. There is often a focus on the high cost of stoma appliances, and they need to be used with careful assessment and clinical judgement, as the cheapest product may not be the most appropriate for the patient. With an anticipated expenditure of about £100 per patient per month (Drug Tariff, 2021) if there are no complications and only an appliance is used,, it is important to ensure that the stoma products used are appropriate. It is usually specialist stoma care nurses who are best placed to advise on stoma products as they have the greatest understanding of stoma care and are, thus, a good source of information.
Figure 2. One-piece drainable ileostomy appliances
A colostomy appliance needs to collect and contain formed faeces and to release flatus. Thus, it will have a filter to release the flatus but not the odour. As the faeces are solid and formed, they are not emptied from the appliance; instead, the appliance is closed. Therefore, a colostomy appliance needs to be replaced when it is a third to half full, which is, on average, once a day. However, bowel function can vary widely, from three bowel motions a day to three bowel motions a week. This equates to the need for between 10 and 90 colostomy appliances per month per patient (Association of Stoma Care Nurses UK (ASCN), 2016).
An ileostomy appliance is used to collect and contain loose faeces and release flatus. To enable this, the appliance will also have a flatus filter, but it will be drainable to enable emptying of the loose faeces. Ileostomy appliances need to be emptied multiple times each day, often four to six times, and, sometimes, also at night. To enable emptying, the appliance has a method to reseal the appliance so that faeces does not leak from the opening. An ileostomy is commonly sealed with a Velcro type fastening and needs to be cleaned at each emptying. Ileostomy appliances are changed from daily to every 3 days. This equates to between 10 and 30 ileostomy appliances per patient each month (ASCN, 2016).
The least commonly formed stoma is the urostomy, and the urostomy appliance is used to collect urine. There is also a small amount of mucus passed from the bowel conduit. To enable drainage of urine into the toilet, the urostomy appliance has a tap or bung at the bottom. To enable undisturbed sleep, most people with a urostomy wear a leg bag or night bag at night-time, attached to the end of their urostomy appliance to increase the urine storage capacity (ASCN, 2016). A urostomy will often need to be emptied four to six times daily and changed every day or two. This equates to between 15 and 30 urostomy appliances per patient per month.
Complications
Although many people with a stoma will have a good quality of life and relatively few complications, it needs to be recognised that complications can and do happen. Additionally, depending on the complication, it is often necessary to provide effective and prompt care if the adherence of the stoma appliance is compromised, as this can result in appliance leaks and embarrassment and can exacerbate skin damage and, thus, increase the chance of appliance leakage. Complications of the stoma include prolapse and retraction, while complications of the skin around the stoma (peristomal skin) include skin erosion and skin infections. Another commonly reported issue is a parastomal hernia.
Prolapse
A prolapsed stoma can be described as the stoma elongating out of the body. A prolapse is reasonably uncommon, occurring in up to 3% of people with a stoma (Krishnamurty et al, 2017). The cause of a prolapsed stoma is uncertain, but is related to increased abdominal pressure or lack of abdominal adhesions to hold the stoma in place. While this is not dangerous at the first occurrence, a prolapsed stoma needs to be urgently reviewed by the surgeon or specialist stoma care nurse. The elongated bowel needs to be carefully examined at each appliance change for signs of damage, such as bleeding or bruising on the surface of the bowel mucosa. Another potential issue is that the prolapsed bowel can, in some situations, be quite large, and this can fill much of the collection capacity of the stoma appliance, leading to more frequent changing or emptying. Additionally, it can make the appliance difficult to apply, as the prolapsed stoma can make visualisation difficult, and it can also be difficult to ensure that the stoma is within the stoma appliance. Treatment can involve manipulating the prolapsed bowel back into the abdominal cavity, and the prolapse could be maintained within the abdominal wall, but it can re-prolapse. This procedure should not be performed by the community nurse or patients without training. Another treatment alternative is to surgically remove the prolapsed segment of bowel. If these two methods are unsuccessful, patients can be taught to change their appliance when lying down, as this encourages the prolapse to return into the abdominal cavity. Wearing a stoma shield and elastic stoma belt can help reduce the amount of prolapse as the stoma is held under the shield (ASCN, 2016).
Retraction
A retracted stoma can be described as one that is level with or below the level of the abdominal wall. In a few cases, retraction can be very extreme, and no bowel mucosa may be visible. Retraction may occur for a number of reasons soon after the stoma is formed or subsequently. A retracted stoma could be as a result of lack of mobilisation of the colon to easily reach the abdominal wall when forming a colostomy. Another reason because of mucocutaneous separation in the post-operative period, where the skin and the stoma detach. When the mucocutaneous separation heals, it can lead to a tight stoma, a stenosis (ASCN, 2016) or a retracted stoma. Retraction can also occur as a result of weight increase after the stoma was formed.
If the output from the stoma is passing into the stoma appliance without difficulty, no treatment is necessary for a retraction. However, if the retraction is causing the output from the stoma to creep under the stoma appliance adhesive, and this is causing skin damage, then intervention is needed. In this situation, a convex appliance is potentially advocated (ASCN, 2016). There are risks associated with using a convex appliance, such as bruising or even ulceration to the skin around the stoma. Therefore, patients must be advised to observe the skin at each appliance change. It is ideal to consult the specialist stoma care nurse for advice before commencing on a convex appliance (ASCN, 2016).
Skin erosion
There are many ways that the peristomal skin can become damaged from erythema to ulceration. In this sense, there is some overlap between tissue viability and stoma care, with the use of terms such as peristomal moisture-associated skin damage (P-MASD) and peristomal medical adhesive-related skin injury (P-MARSI) (Burch et al, 2021). Within the category of P-MASD is irritant contact dermatitis due to a leaking stoma appliance. It is important to note that early skin damage, such as erythema, is less easy to detect on darker skin tones than light ones. To treat skin damage, it is important to assess the cause, which might range from skin stripping to allergy. Skin stripping can occur if the appliance is removed without care, taking with the adhesive the surface of the skin. Treatment is re-education, if the removal of the appliance is rough. However, if there is really fragile skin around the stoma, such as if the skin is thin, stretched, older or weakened, it might be advantageous to use an adhesive remover spray or wipe to help dissolve the adhesive (Burch et al, 2021). If skin damage has occurred because the aperture in the appliance is too large (Figure 1) or too small, then this should be re-sized (ASCN, 2016) to be 2–3 mm larger than the stoma and to the same shape. If the faecal output is very corrosive to the skin, a skin barrier film can be of use; this is more likely to be necessary for a patient with an ileostomy due to the proteolytic enzymes in the faeces.
An allergy to the stoma appliance is very rare, and, if suspected, referral to a specialist stoma care nurse is advocated. For skin that is wet but with only superficial skin erosion, the use of a stoma powder will help dry the damaged area and enable the stoma appliance to adhere. It is important to note and to remind patients that too much powder will prevent the appliance from adhering. The correct way to use the powder is to ensure that just a thin dusting is on skin that is moist, and no powder is on intact skin. It will not do the stoma harm for powder to touch it, but it is unnecessary to add it to the stoma deliberately. It is possible that, over time, stoma care is forgotten or that the abdominal wall changes shape and changes are required to care. Health professionals and people with stomas often need to be reminded of the importance of careful cleaning and drying of the peristomal skin, as well as a correctly sized aperture that is accurately applied and held on for 30 seconds.
Skin infection
The most common skin infection in the UK is folliculitis, that is, inflamed hair follicles (Burch et al, 2021). This presents as red spots or pustules at the hair follicles under the stoma appliance. To resolve this, the hairs that are under the stoma appliance should be clipped or carefully shaved once a week. In hot weather, it is possible for a fungal infection to occur. This is seen as erythema with oedema and will need a topical antifungal treatment, used sparingly.
Parastomal hernia
A parastomal hernia is a bulge of the abdominal contents around the stoma, presenting as a swelling around the stoma. Most parastomal hernias will occur within the first 2 years after stoma formation (Krishnamurty et al, 2017). For this to be accurately diagnosed, an MRI is needed, so if there is any doubt, the patient should be advised that they have a parastomal swelling that might be a hernia. There is some evidence that a parastomal hernia can be prevented if patients undertake daily abdominal exercises to strengthen their abdominal muscles after they have their stoma formed and wear an abdominal support (North and Osborne, 2017). However, which of these interventions is more important and whether both are needed is uncertain. In general, patients are able to walk as soon as they return home from the hospital after the stoma-forming surgery, and other activities can be gradually added to their lifestyle as general fitness allows. It is advisable not to carry heavy items for at least 4 weeks (ASCN, 2016), and this can be extended if there was a laparotomy rather than laparoscopic operation. For many people, 3 months is when normal activities can be resumed, but it is better to check with the surgeon as each person can be different. If a parastomal hernia has already developed, the most common intervention is conservative, such as wearing a support belt (ASCN, 2016). Another option is surgical repair of the hernia, but, as about half of those affected will develop another parastomal hernia, this option is not often undertaken. Support belts are available on prescription, but, due to the cost, some GPs are reluctant to prescribe them.
Conclusion
It is advocated that people with stomas have their stoma and products reviewed each year, and this is ideally undertaken by the specialist stoma care nurse. If a person has lost touch with the specialist stoma care nurse, it is useful to remind them of this service and ask the GP for a referral, particularly if there are repeated issues with the stoma or the peristomal skin.
Community based nurses are in an ideal position to assist people with some of the complications that can arise with having a stoma. These complications can relate to the stoma or the skin around the stoma. Simple measures such as reminding patients about caring for their stoma can solve some of these problems, although other issues can be more complex. The specialist stoma care nurse is often a good source of advice and support if needed.
KEY POINTS
- Community nurses are well placed to assist people with a stoma to manage stoma-related complications
- Complications can relate to the stoma such as retraction or prolapse, as well as to the peristomal skin such as skin erosion or skin infection
- When a patient with a stoma is reporting repeated stoma-related problems, consider referral to the specialist stoma care nurse
CPD REFLECTIVE QUESTIONS
- Consider your clinical practice, how can you help your patients to avoid formation of a parastomal hernia?
- How can the experiences with wound healing be translated into peristomal skin care in your clinical practice?
- Reflecting on a situation with a patient with a stoma that did not go as well as it could have, what might you do differently now you have additional knowledge of stoma care?