STOMA CARE IN NEWBORN

1. CARE OF STOMAS

2.  A stoma is a surgical
bypass of a natural
conduit.
 It is practiced when
the natural channel
can no longer fulfill
its role, as a result of
disease, trauma or
an ablation

3.  There are many reasons why a newborn or child
may need an ostomy.
 It is often a life-saving operation
 Stomas should be red like the inside of your
mouth, and they should be moist and soft.
 Stomas might bleed a little when rubbed or
touched.
 This is normal because stomas have a lot of blood
vessels.
 They also don't hurt when touched because there
are no nerve endings

4.  Stoma may differ from each other
 They may be permanent or temporary
 Some children have more than one stoma.
 They can be located on different parts of
the body
 Stomas may be different shapes and sizes.
 They may stick out above or be slightly
below the skin level.

5. location of stomas
 Ileostomy
 Colostomy
 Vesicostomy
 Ureterostomy
 Gastrostomy
 Oesophagostomy

6. Condition may require stoma
Neonatal Conditions
 Necrotizing enterocolitis
 Ano rectal malformation
 Hirschsprungs Disease
 Meconium ileus
 Intestinal atresias
 Trauma
Childhood
 Inflammatory Bowel disease
 Malrotation
 Pseudo obstruction

7. Types stoma
 Stomas are used in situation in which diversion
of, decompression of or access to the bowel
lumen is needed
 Types
End Stoma
Loop Stoma

8. Importance of Stoma Care
 Prevention of infection
 Prevention of skin breakdown
 Prevention of complication

9. Nursing Care
 Pre operative Care
- Informed written consent from parents
- Psychological preparation of parents
- Sterilization of bowel if needed
- Skin preparation
- Restriction of oral intake prior to surgery

10. Post operative Care
 After surgery, the stoma may be swollen. It is
common for it to change size and get smaller.
 Observe stoma for color, swelling, trauma,
bleeding and healing.
 Stoma should be moist and reddish pink
 Auscultate for bowel sounds.
 Measure abdominal girth
 Observe abdominal incision for any sign of
infection

11.  Provide peristomal skin care.
 Clean skin gently with warm water
 Allow skin to air dry.
 Asses frequency, colour and consistency of
stool
 Note signs and symptoms of obstruction
 Provide adequate hydration
Post operative Care

12. Issues after stoma
 Contain digestive enzymes
 Cause the skin breakdown
 Consistency- liquid to pasty
 Offensive odor
 Dehydration
 Infection

13. Prerequisites stoma care
 Explain to the child or parent
 Verbal consent
 Hygienic environment
 Provide comfortable position
 Provide privacy in case of older children
 Assemble articles
 Personnel protective equipments
 Recording sheet/ chart

14. Articles needed
 Clean tray containing
 Dressing set
 Normal Saline, Povidone Iodine
 Paraffin gauze/ Coconut oil soaked gauze
 Stoma cover
 Paper bag and kidney tray
 Mackintosh and sheet
 Personal protective equipments

15. Assessment
 Identify the child
 Check the diagnosis and general condition
 Assess the need for stoma care
 Assessment of the site
Preparation of the child
 Explain in simple language
 Provide comfortable position
Procédure

16. Procedure
 Ensure warm & clean environment
 Arrange all articles near bedside
 Provide privacy
 Hand washing
 Removal of the covering gauze/
bandage/pouch
 Clean in circular manner
 Place paraffin or oil soaked gauze over
the stoma/apply new pouch

17.  Cover with sterile pad and bandage/cover
 After care of the articles
 Wash hands
 Record the care provided Condition of the
child, Appearance of the stoma

18. Steps Actions
1 Observe colour of the stoma. Observe and document stoma for
perfusion, bleeding, skin integrity and signs of infection or
prolapse every 4-6 hours.
2 Measure stoma output. Notify medical staff if there is >30-
49mls/kg/day stoma output
3 Ensure the skin surrounding the stoma is protected from
excoriating effects of enzymes by: Check stoma with cares 4 to
6 hourly for wound ooze, bleeding (small spots of blood
common with cleaning) and bowel motion. Clean with warm
sterile saline until wound suture line healed then warm
sterile water can be used
4 Post operatively: Measure stoma and cut a hole in the flange
of the Hollister Newborn appliance to fit over the stoma, apply
then put Newborn pouch onto skin barrier. This should be done
immediately post operatively for protection of skin and stoma.
The stoma can be viewed through the clear pouch or the pouch
can be removed from the flange if the stoma needs to be
viewed more closely

19. Steps Actions
4 In the first week post op the stoma will decrease in size as
the swelling resolves, therefore the size of the hole cut in
the flange will need re-measuring (when new pouch
applied).
Stabilising the Stoma
Follow the steps below to ensure stoma is stabilised.
1 Stoma pouch must be changed every 3-47 days, or as
soon as it leaks
2 Check flange and pouch with cares, ensure flange is not
leaking, if the flange is stained underneath then it has
leaked and needs to be changed. Pouch needs to be
emptied when 1/3 full of bowel motion or gas as it will
lift the flange
3 To change pouch if leaking: Gather equipment: gloves,
bowl, warm water (no soap), gauze, cotton buds,
appropriate sized bag and clip, scissors, flange backing
for size

20. Steps Actions
4 Carefully remove old pouch from the top edge
downwards, clean skin with warm water, dry well;
assess skin for any signs of excoriation. Assess
stoma for any changes in colour, size or excessive
bleeding.
1 If skin is looking red, use the cavilon no sting barrier
film and allow to dry
2 Cut hole in flange to fit the size and shape of stoma,
the flange needs to fit over the stoma with a gap of
approximately 2mm from edge of stoma to flange. If
the flange is too close to the stoma then the mucus
from the stoma will cause the flange to lift. If the
flange is not close enough to the stoma then the
surrounding skin could become excoriated.

21. Steps Actions
Warm flange between hands for approximately one
minute. Apply flange and apply pressure to the flange
for one minute and press down all edges. Check the
flange is well attached and apply pouch. Close end of
pouch with clip provided

22. Skin barrier
application
Plasticized skin
covering
Stoma care

23. Stoma covering

24. Parent counseling
 Most important of stoma care
 Peristomal skin care
 Clean the skin with warm water before
changing pouch
 If possible, change the pouch when the
stoma is less active
 A toy or mobile can help to distract a wiggly
child and keep them occupied during the
pouch change

25.  can bathe the child with the pouch on or off.
Water/soap will not harm the stoma
 Sleeping on their tummy will not hurt the
stoma, although it is recommended that
infants should sleep on their backs for other
medical reasons.
 the stoma will not prevent him or her from
normal movement
 When selecting outfits, avoid clothes where
the waistband rubs against the stoma

26.  DIET
 Breast feeding offers many advantages for both
baby and mom
 If your baby is in the Neonatal Intensive Care
Unit (NICU), you may need to use a breast
pump and save your milk until your infant can
be fed.
 New foods can be added to your baby's diet as
recommended
 When a new food is added, it may change the
color or consistency of your child's stool or
may result in more gas. This is normal

27.  If there is no output from the stoma for a
prolonged period and the child experiences
cramping, diarrhea or bloating, it needs
medical attention
 Fluid intake is important for all children.
Infants and children with ileostomies can
quickly become dehydrated

28.  Feed Intolerance symptoms
 Increasing gastric residuals
 Emesis
 Abdominal distension
 Visible loops of bowel
 Altered stool characteristics

29. Complications
 Skin irritation: The skin around the stoma can
become irritated. Some of these skin breakdowns
are minor and improve quickly

30.  Prolapsed stoma: This occurs when the
stoma changes and becomes longer or larger
than it had been. If this happens, it can be of
concern. It occurs in end or loop stomas

31.  Retracted stoma: This happens when the
stoma sinks below skin level. It may occur
when the stoma swelling goes down or your
child gains weight. Both are normal.

32.  Dehydration:
 Any child can develop diarrhea which may
also be accompanied by vomiting. This can
cause dehydration. Dehydration occurs when
they lose too much fluid and are not able to
replace it by drinking
 Bleeding: The stoma may bleed and this is
normal. However, if the bleeding does not
stop, contact your doctor immediately.

33. STOMA ASSESSMENT CHECKLIST
S.No Criteria Expected Results Remarks
1. Condition of the surrounding skin Healthy (No
Excoriations)
Unhealthy
(Excoriation)
2. Pus discharge Absent Present
3. Ulcers on the stoma Absent Present
4. Bleeding from stoma No bleeding/Minimal
Bleeding
Moderate to severe
bleeding
5. Passage of stool from the rectum Absent Present
Grading of stoma:
4-5 : Healthy Stoma
0-3: Unhealthy Stoma

34. Medical Adhesives

35.  Adhesive injury is the most common source of
skin breakdown in infants in the NICU
 Different types of medical adhesives are used in
tapes and wound dressings.
 Because of diminished cohesion between the
epidermis and dermis, even one removal of an
adhesive can result in alteration in skin barrier
function

36.  Select and use medical adhesives like
lecoplast, durapore, dynaplast etc
appropriately to secure life support,
monitoring and other devices in all
newborns.
 A study including adult volunteers demonstrated
an increase in “Peel force”-or amount of force
needed to remove the adhesive from the skin –
has been shown to increase the level of
discomfort with adhesive removal and cause
trauma, which reduces skin barrier function and
increase cutaneous irritancy

38.  Choose medical adhesives that cause the least
tissue trauma while effectively securing medical
devices (such as endotracheal tubes,
intravascular catheters, and nasogastric tubes)
and monitoring equipment, as well as wound
dressings.
 Durapore
 Dynplast
 Lecoplast
 Micropore

40.  Removal of medical adhesives can cause
trauma, such as skin stripping and pain
 Protect the underline skin with tegaderm
(polyurethanes) before these adhesives
application.

41. How to Remove Adhesives
 Remove adhesive slowly and carefully using
a warm saline swab or gauze piece
 Pull medical adhesive tapes on a horizontal
plane, folding the tape back onto itself while
continuously wetting the adhesive-skin
interface.
 Alternatively use mineral oil or petroleum to
loosen tape unless retaping is necessary at
the site.

42. Avoid using the following products
whenever possible
 Alcohol/Organic-based products
 Oil-based solvents
 Enhancing bounding agents
 Adhesive bandages after laboratory samples.
 Application of adhesives should be avoided
whenever possible. Pressure with a cotton ball
may be sufficient to stop bleeding

43. Anetoderma
 Anetoderma is defined as atrophic patches
of skin caused by dermal thinning.
 A series of nine infants 24-29 weeks of
gestation, were noted to have atrophic skin
lesions, located on the abdomen, chest,
upper arms, and thighs, associated with
placement of monitoring leads or
temperature probes

44. Emollients

45. Introduction
 Emollients protect the integrity of the
stratum corneum and enhance barriers
function
 Emollients can reduce or treat dry scaly
skin, cracking or fissures on skin, surfaces
 Friction may cause skin irritation and
breakdown, especially in very-low-birth
weight babies
 the use of emollients is effective in treating
dry or cracked skin

46. Use of Emollients
 At the first sign of dryness, fissures or flaking
apply an emollient every 12 hours or as needed.
 Apply emollient gently to skin, especially with
very low-bithweight neonates, to avoid friction.
 Observe for development of systemic infections,
such as coagulase-negative staphylococcus
infections, especially in neonates weighing less
than 750 grams.

47.  Emollients should be provided in unit in baby -
specific containers.
 Maintain sterility of the emollient container.
 All surrounding treatment surfaces that may be
contaminated by emollients should be
thoroughly cleaned.
 Emollients may interfere with adherence of
adhesives.

48.  Emollients may be used to treat discrete areas
of skin dryness, flaking or fissures for infants
on radiant warming tables or receiving
phototherapy
 Transepidermal water loss was reduced when a
clear topical ointment was used on jaundiced
preterm infants under phototherapy

49. Carry home message
 Meticulous skin care
 Daily stomal assessment
 Dietary education
 Regular diet
 Avoid raw fruits and vegetables
 Avoid gas forming foods
 Plenty of water
 Body hygiene
 Regular follow up
 Distal stoma wash
 Indigenous stoma care system
 Medical adhesives