Management of the Adult Patient With a Fecal or Urinary Ostomy
RECOMMENDATIONS
A. Stoma Construction
1. Construct fecal and urinary ostomies, whenever possible, to protrude above the surface of the skin.
(Level C, Class I, )2. Mature ileostomies and urostomies at least 2 cm above the level of the skin’s surface to help minimize peristomal leakage.
(Level C, Class I, )B. Preoperative Education
2. Focus on self-care of the ostomy and/or assistance of a caregiver, as needed, when providing preoperative ostomy education.
(Level C, Class I, )C. Stoma Site Marking
Ensure preoperative stoma site marking is performed by a trained clinician to promote patient independence in stomal care, promote resumption of normal activities of daily living, and reduce postoperative complications.
(Level B, Class I, )D. Selection of an Ostomy Pouching System
1. Establish a pouching system that maintains a seal for a predictable amount of time without leakage and protects the peristomal skin.
(Level C, Class I, )2. Advise the patient to seek assistance from a WOC nurse or a nurse skilled in ostomy care to assist in the selection of an effective pouching system.
(Level C, Class I, )3. Consider the following factors when selecting a pouching system: type of ostomy, stoma type and location, abdominal contours, lifestyle, personal preferences, visual acuity, and manual dexterity.
(Level C, Class I, )4. Measure the stoma and fit the opening in the skin barrier of the pouching system to the size and shape of the stoma.
(Level C, Class I, )5. Consider using convexity when wear time of the pouching system is not desirable, the peristomal skin is creased (wrinkles/folds), the stoma is retracted and/or flush, the opening of the stoma (os) is at/or below the skin level, and/or if the peristomal skin is flaccid.
(Level C, Class I, )6. Consider using accessory ostomy products if needed to enhance the effectiveness of the adhesive seal of the pouching system and/or protect the peristomal skin.
(Level C, Class I, )7. Determine the type of pouching system (1- or 2-piece) for the person with a stoma based on the physical needs and personal preferences of the individual.
(Level C, Class I, )E. Postoperative Education
Include the following key components in postoperative education before the patient is discharged from the hospital: assessment and care of the stoma and peristomal skin, pouch emptying, changing the pouching system, drainage collectors for urostomies, managing gas and odor, common complications, clothing, diet and fluid guidelines, medications, use of a medical alert bracelet by a patient with a continent ostomy, and obtaining supplies.
(Level B, Class I, )F. Postoperative Management Issues
1. Consider colostomy irrigation as one of the management options for the person with a sigmoid or descending colostomy.
(Level C, Class II, )2. Provide counseling and support to the person with an ostomy based on an assessment and identification of cultural, religious, and sexual/intimacy issues.
(Level C, Class II, )3. Implement measures to manage a high ileostomy output.
- Include high sodium and complex starches in the diet.
- Avoid sugary drinks, including juices.
• Monitor and record weights.
• Use antidiarrheal medications, such as loperamide, as directed by the healthcare team.
• Seek medical attention when high output and signs/symptoms of dehydration are present.
c. Consider developing and implementing a pathway, protocol, or plan of care that addresses management of a high ileostomy output.
4. Obtain a urine sample for culture from a urostomy by catheterizing the stoma, which is the preferred method.
(Level C, Class II, )G. Follow-up Care After Discharge From the Acute Care Setting
Utilize a standardized approach to provide ongoing follow-up care and support to patients with a new ostomy (after their discharge) by an ostomy nurse specialist through an outpatient ostomy clinic, a home healthcare agency, and/or telephone follow-up.
(Level C, Class II, )H. Health-Related Quality of Life for the Person With an Ostomy
2. Provide 12 months of follow-up after surgery to promote effective coping with an ostomy.
3. Refer individuals with new ostomies who have a severe or prolonged decrease in their HRQOL to appropriate healthcare providers.
4. Provide information to individuals with new ostomies about community-based ostomy groups, ostomy visitors, and online ostomy support groups.
I. Stomal and Peristomal Complications
1. Mucocutaneous separation
a. Treat the mucocutaneous separation according to the depth and degree of the defect:
- Consider sprinkling stoma powder over the separation to absorb moisture and promote better pouch adherence if the separation is shallow.
- Consider filling the separation with an absorbent product, such as an alginate or gelling fiber, and covering it with a solid hydrocolloid or the pouch’s skin barrier if the separation has depth.
c. Determine appropriate systemic antibiotic therapy if infection occurs. (Level C, Class II, )
2. Stomal necrosis
a. Consider marking the potential stoma site in an obese patient in the upper abdominal quadrant, which may decrease the extent of surgical dissection of the mesentery that is necessary and minimize vascular compromise to the stoma.
(Level C, Class II, )- Monitor and observe the stoma if the necrosis is superficial. The top layer of tissue may slough off over time, revealing a red viable stoma.
- Determine if debridement of the nonviable stomal tissue is necessary if the ischemia and necrosis are deeper.
- Refer the patient for emergent surgical revision if necrosis is below the fascial level.
3. Stomal retraction
- Consider the use of a convex pouching system and/or a belt.
- Consider the risks and benefits of convexity. There is little evidence in the literature regarding how soon after ostomy surgery convexity may be introduced.
4. Stomal stenosis
b. Consider stomal dilation only on a temporary basis to aid in evacuation. Due to a lack of evidence, dilation is not recommended as a long-term practice, and chronic use of dilation is associated with stomal stenosis.
c. Determine if surgery is necessary to correct the stenosis.
5. Stomal prolapse
- Adjust the size of the pouch and the opening in the skin barrier to prevent trauma to the stoma.
- Use a hernia support belt with a prolapse attachment.
- Determine if a 1-piece pouching system might minimize trauma to the prolapsed stoma, depending on the length of the prolapse.
- Educate the patient or caregiver regarding techniques to reduce the prolapsed stoma, assessment of the prolapsed stoma for color changes, and to seek medical attention if the stoma becomes dusky or ischemic.
6. Peristomal (also known as parastomal) hernia
b. Consider the following interventions: Use a hernia support belt, discontinue colostomy irrigations if water and stool do not easily return, and use a flexible pouching system to prevent peristomal skin trauma.
c. Instruct patients to immediately report the following symptoms to their healthcare provider: stoma darkens in color or unremitting pain; no gas, stool, or urine from the stoma; or bloating, nausea, vomiting, and loss of appetite.
d. Refer the patient for urgent surgical intervention if the hernia incarcerates and/or the color of the stoma changes.
7. Stomal trauma
b. Advise the patient to use caution and consider using stoma protection devices when participating in sports/activities.
c. Instruct the patient to promptly report persistent bleeding or bleeding that comes from inside the stoma to the healthcare provider to rule out other disease-related complications. (Level C, Class I, )
8. Stomal fistula
b. Correct any underlying medical condition(s) that might contribute to the development of a fistula (eg, Crohn’s disease).
c. Consider surgical intervention to revise or relocate the stoma if the stomal fistula cannot be managed by making alterations in the pouching system.
9. General peristomal recommendations
a. Identify and manage the underlying cause of peristomal complications while providing appropriate care.
(Level C, Class I, )b. Evaluate the peristomal skin. Remove the ostomy pouching system and assess the peristomal skin. Examine the back of the skin barrier (the adhesive side) to see if stomal effluent has been getting under the skin barrier, and determine if leakage is affecting the condition of the skin.
(Level C, Class I, )c. Ensure the pouching system fits well throughout treatment to protect the peristomal skin and prevent additional damage (ie, covers the skin around the stoma; maintains a seal for a predictable amount of time without leakage). Change the type of pouching system and the frequency for changing the pouching system, if needed, while the skin is healing.
(Level C, Class I, )10. Peristomal moisture-associated skin damage
b. Provide a pouching system that fits closely around the stoma and prevents leakage under the skin barrier.
c. Advise the patient with a urostomy to connect the pouch to a bedside drainage bag at night to help prevent urine from undermining the skin barrier and causing leakage.
d. Treat damaged skin with stoma powder and a no-sting barrier film or a solid skin barrier, as indicated.
e. Consider local treatment of wart-like lesions:
• Apply vinegar and water soaks to the affected area while the pouching system is off.
• Evaluate any lesions that do not resolve to rule out possible malignancy.
11. Peristomal fungal/candidiasis infection
b. Eliminate moisture from the affected area: Instruct the patient to change the pouch if moisture has gotten beneath the skin barrier.
12. Peristomal allergic contact dermatitis
b. Apply a topical corticosteroid spray to manage inflammation and provide symptom relief. Avoid creams and ointments, which interfere with adherence of the pouching system.
c. Adjust the frequency of pouch changes, if needed. The patient may need to remove and replace the pouch more often until the skin irritation has resolved. (Level C, Class I, )
13. Peristomal mechanical skin damage: Medical adhesive– related skin injury (MARSI).
b. Manage open skin area(s) by applying stoma powder or an absorbent dressing prior to application of the solid skin barrier.
c. Consider selecting a pouching system without tape borders if tape is contributing to the skin injury, and use adhesive removers when changing the solid skin barrier.
d. Consider use of skin barrier films to help protect intact, fragile skin.
14. Peristomal mechanical skin damage: Medical device–related pressure injury (MDRPI)
b. Use absorbent products such as stoma powder, alginate dressings, and polyurethane foam to absorb excess moisture from healing wounds.
c. Instruct the patient to change the pouch more frequently until the wound has healed to ensure moisture does not accumulate beneath the skin barrier. (Level C, Class I, )
15. Peristomal varices
b. Refer patients with uncontrolled hemorrhage for urgent medical attention.
c. Use skin barriers that are easily removed, and use adhesive removers when possible.
d. Avoid using rigid ostomy products that may cause injury.
e. Refer the patient for a medical workup to determine the etiology of varices and possible treatment. (Level C, Class I, )
16. Peristomal folliculitis
b. Apply topical antibiotic powder in severe cases.
c. Reduce the frequency of shaving or use clippers.
d. Educate the patient about the condition and how to manage it.
e. Consider methods of permanent hair removal for patients with permanent stomas and problematic or persistent folliculitis. (Level C, Class II, )
17. Peristomal pyoderma gangrenosum
c. Provide appropriate topical care:
•. Fill the wound with an absorbent product, such as an alginate or gelling fiber, to facilitate adherence of the ostomy skin barrier.
• Adjust the frequency of pouch changes to ensure moisture does not accumulate on the intact skin.
• Consider topical treatment of mild PG with tacrolimus, which, based on reports from treatments of small numbers of patients, may be effective to promote healing.
d. Determine the need for systemic management for patients who do not respond to topical/local therapy or have more severe PG:
- Consider use of other anti–tumor necrosis factor (anti-TNF) agents, such as infliximab.
18. Peristomal suture granulomas
b. Gently probe the affected area to locate any retained sutures and remove them, if possible.
c. Apply silver nitrate to the elevated areas of tissue, if needed.
d. Apply stoma powder to the affected area to absorb excess moisture before the pouching system is applied. (Level C, Class II, )
Recommendation Grading
Disclaimer
Overview
Title
Management of the Adult Patient With a Fecal or Urinary Ostomy
Authoring Organization
Wound, Ostomy and Continence Nurses Society
Publication Month/Year
January 1, 2018
Last Updated Month/Year
June 7, 2023
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Adult, Older adult
Health Care Settings
Ambulatory
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Diagnosis, Prevention, Management, Treatment
Diseases/Conditions (MeSH)
D010030 - Ostomy
Keywords
Fecal, Urinary Ostomy, Clinical Guideline, Stoma Construction, ostomy pouching system