Pediatric Ostomy Care by Leah Abecassis.
In this video, we're going to discuss the most common reasons for bowel diversion in
pediatrics, including the types of bowel diversions, principles of care, how to patch a stoma,
and what to do if you find a peristomal skin injury.
Introduction to Bowel Diversion.
Bowel diversion surgery is when the normal route of digestion is changed to divert stool
from its typical flow through the bowel.
In pediatrics, there are congenital and acquired reasons for bowel diversions to occur.
Based upon the clinical condition, some may be temporary and others are long term diversions.
Types of Bowel Diversions
There are also different types of diversions and each is named in relation to where they
have surgically been created in the gastrointestinal tract.
In performing a diversion, the bowel is pulled through to the abdominal surface and an ostomy
is created.
Jejunostomy is formed in the jejunum, ileostomy is formed in the ilium and colostomy in the
colon.
Depending on the clinical scenario.
ostomies can be created in any area of the bowel: proximal, distal, ascending, or transverse
to allow stool to bypass the injured or diseased area.
The location of the diversion determines the consistency of the stool.
For example, stool that comes from a part of the intestine closer to the beginning,
like a jejunostomy will have a much higher acidity, be liquid in nature, and be continuous
in output.
Whereas ostomies located towards the end of the large bowel will have a more formed stool
and a more predictable pattern of stooling.
It is important to know where the ostomy is located in the bowel to select the best type
of pouch needed to collect the output.
For example, an ileostomy may have large amounts of liquid output and might be best served
with a spouted end pouch to allow for it to be attached to a drainage system.
In contrast, a colostomy might only need a stoma cover with a filter to release gas that
can be removed when it is time to empty the bowel.
The location, reason for diversion, and extent of bowel involvement often determines where
in the bowel segments surgical diversion is indicated and the type of surgical procedure
done.
in pediatrics, the most common bowel diversion is an end stoma, or the functional portion,
with or without a mucus fistula, the non-functional limb reserved for future reconnection to achieve
bowel continuity, or a loop stoma.
In pediatrics, the stoma is typically pouched even when the child has control of bowel movements.
An end stoma is what is created by the surgeon when the end of the proximal bowel is brought
out through a tiny opening in the abdominal wall and is folded over like a cuff and sutured
in place.
When this occurs, the surgeon may choose to leave the distal part of the bowel internal
or may pull that through an opening in the abdomen to create a mucus fistula.
A loop stoma is when a loop of bowel is pulled through the abdominal wall and cut before
pulling it down like a cuff to suture to the abdomen.
Pouching a Stoma.
A stoma is the name for the opening in the abdomen that is the visible part of the ostomy.
Ideally, stomas are budded one to two centimeters above the abdominal surface with stool exiting
at the top of the stoma so that stool empties into a pouch.
When stomas are flatter to the skin surface, they are more challenging to manage as stool
exits at skin level and may leak under the barrier instead of into the pouch.
When clinically feasible, a common location for the stoma is the lower abdominal quadrants
within the rectus muscle.
Ideally, the surrounding skin is flat without incisions or scars that may create uneven
surface.
The upper abdominal quadrants may be optimal for older, obese or physically handicapped
patients.
The pouch and accessory product selection depend on a number of variables such as size
of the patient, stool volume, and consistency.
Pouching is an art and modifications will need to be made if the stoma is flat, prolapsed,
or constructed in skinfolds.
A 24 hour wear-time is the goal for premature infants and neonates.
Older patients will ideally wear a pouch for two to four days without leakage.
This will keep the skin around the stoma healthy, decrease cost from use of products and increase
patient comfort.
One piece ostomy pouches are often suitable for pediatric patients as they are flexible
and easily contour over rounded abdomens.
Most small sized pouches can be cut to fit a variety of stoma sizes.
A measuring card is used to determine the size of the opening to be cut in the barrier.
When measured appropriately, the barrier will fit snugly around the stoma base.
If an opening is cut too large in the barrier, then skin surrounding the stoma will be exposed
to stool and have increased risk to become irritated.
If the barrier opening is cut too tight, this can lead to decreased circulation to the stoma
and irritation of the stoma with possible bleeding from lacerations.
To expedite the process and minimize stress while changing an ostomy pouch, it is helpful
to have all supplies ready in advance.
Stoma measuring card, gauze, washcloths, paper towels, scissors, and an ostomy pouch selected
for the patient's size.
It is acceptable to have one pouch cut in advance to facilitate a quicker pouch change
but not advisable to cut multiple pouches in advance, especially with a new stoma.
Over time, the stoma becomes smaller and less edematous and the opening would be too large.
The application of additional products may also require changes to the barrier opening.
When removing the old pouch, gently lift the barrier from the skin using gauze and water
to help release the adherence to the skin.
Some find it helpful to use adhesive removers if they are available.
Try to avoid lifting and tenting up the skin because that can lead to separation of the
epidermal layer from the dermal layer of the skin causing damage.
Once the pouch is removed, clean the skin with a soft wash cloth or paper towel moistened
with water.
Consider using soap if stool residue was adherent to the skin.
Assess the stoma.
It should be moist, pink or red similar to the inside of your cheek and the surrounding
skin should have no rashes or other skin compromise.
Evaluate the height of the stoma, whether it is flat, rosebud shaped, retracted or prolapsed.
Measure the stoma with a measuring card fitting closely around the base of the stoma.
Then use that as your guide to cut an opening in the barrier that leaves minimal skin exposed
around the stoma.
After cutting the barrier opening, warm the new pouch with a warm pack or your hands to
improve its adherence to the skin.
Pastes and moldable rings can be used to fill in uneven skin contours or folds and prevents
stool from getting under the barrier.
For flat or retracted stomas there are also convex, bowl-shaped moldable rings which may
decrease the risk of leakage under the barrier and improve adherence.
Ostomy pouches with built in convexity with a bowl shaped part that curves inward towards
the skin are another option for flat stomas if available to create an artificial lift
to the stoma.
Place the new pouch on the skin carefully in a position that allows the pouch to be
emptied most easily.
The typical direction of the pouch opening for
an infant who mostly lies down is off to the side of the body.
For an older child who empties the pouch into a toilet the direction of the opening should
be facing down towards the feet.
To optimize adherence of the pouch to the skin, after placing the pouch on the skin
warm the barrier a second time with your hands or warm packs.
The most common type of skin injury seen in the skin surrounding the stoma occurs from
stool leaking under the barrier.
The skin under the barrier can be erythematous and become macerated and a rash may form.
Another type of skin damage that can occur is from patients having a reaction to the
materials that some barriers are made from.
Management for either case begins with identifying the cause of the skin irritation, such as
poor barrier adherence to the skin.
If the barrier is intact and there is no leakage then the likely reason is sensitivity to the
barrier and a change in product line or manufacturer needs to be considered.
If the skin is raw, wet or open, the first basic treatment will be skin protective powder
lightly padded with a protective barrier wipe to form a crust.
Once that dries after one to two minutes, then the ostomy pouch can be applied.
Thank you for watching this video on pediatric ostomy care.