Problems in stoma care and wound management in the infant with NEC

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• Problems in stoma care and wound management in
  the infant with NEC
• Alison Broadbent Fiona Metcalfe
• Neonatal and Paediatric Surgical Outreach Sisters
• Leeds Teaching Hospitals

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Conditions Predisposing to Stomas

• In the Neonate,
• Hirschprungs Disease.
• Ano-Rectal Malformation.
• Necrotising Enterocolitis.

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Types of Stoma

• There are two basic types of stoma relating to
  the bowel,
• Colostomy an opening into the colon, large bowel.
• Ileostomy an opening into the ileum, small bowel.
• (Typical for infants with NEC and usually
  temporary)

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Ileostomy
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Ileostomy

• Effluent thinner
• Loss of fluid
• may need replacement if gt 20ml/kg/day
• May need Loperamide
• Loss of Sodium
• may need sodium supplementation
• Skin excoriation
• Spout on stoma

• Nutritional deficits
• Nutritional status vitally important
• Measure stoma loss 4hourly

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Complications of stomas

• Skin excoriation
• Prolapsed proximal limb or distal limb
• Retraction
• Stenosis - Constipation
• Diarrhoea (infantsgt 20mls per kg in
  24hrs)
• Parastomal herniation
• Bleeding/Granulation tissue
• Necrosis
  

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Common Concerns / Sore Skin

• Risk factors due to preterm skin e.g..
  Lessdermal/epidermal layers, fluid
  loss,infection, absorption.
• Is the area affected immediately around the
  stoma?
• Has the appliance been left on too long?
• Poor technique when changing the appliance?
• Is it the appropriate appliance?
• Are there any leakages?
• Has the infants physique altered?
• Does the sore skin correspond exactly to the
  adhesive area of the appliance?
• Pre existing skin conditions? E.g. eczema,
  infection, Fungal

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Prevention of Skin problems

• Good stoma care
• Barrier products
• Enteral feeding
• Medications

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NORMAL STOMA CARE

• Gentle/ careful removal of appliance- every1-3
  days
• Gentle cleansing- with wipes not cotton wool, no
  soaps
• Protect Skin from effluent
• Appropriate use of stoma products e.g. barrier
  wipes, stoma pastes/powders, adhesive remover
• Choose suitable appliance/pouch/flange size
• Correct fit- around stoma/s, infant size
• Warm flange before sticking to aid
  adhesion/moulding
• Small amount of bleeding is normal when cleaning
• Lots of products to choose from SEEK ADVICE from
  stoma care nurse

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Prolapsed Stoma

• The stoma increases in length above the surface
  of the abdomen.
• Most often results from an overly large opening
  in the abdominal wall or inadequate fixation of
  the bowel to the abdominal wall.
• Surgical correction is required when blood supply
  is compromised.

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Conservative treatment for prolapsed of stoma

• Select appropriate bag and flange size
• Large enough to hold stoma without trauma
• Use clear appliance
• Observe for oedema,colour change or engorgement

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Retracted Stoma

• This is the opposite of prolapsed.
• This is when the stoma sinks below the abdominal
  skin
• Makes pouches more difficult to stick.
• No concern if functioning but good to inform
  medical staff of change.
• Nurse Management
• Managing exit site, Appropriate stoma flanges and
  Skin barrier products

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Infection

• Candida
• Staph Aureus
• Impregnated stoma appliance?
• Non grease topical cream
• Nurse Management
• Nystatin with Orahesive powder
• Oral Nystatin
• Hydrocolloid stoma flange

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Wound dehiscence and stoma management
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Risk Factors for wound Problems

• May be due to a number of reasons
• Elective or emergency procedure
• Poor nutrition
• Use of steroids affect healing of mucosa
• Stoma positioning not appropriate to appliance
  fixation
• Infection

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Blue Peter tactics
REF Fretwell et al (2004) Gastrointestinal
nursing. Vol 2, No5
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(No Transcript)
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Wound Assessment Care Plan
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Wound assessment Flow Chart
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Barrier products

• Pastes eg. Orabase
• Powders eg. Orahesive
• Wipes eg.Cavalon
• Wafers eg. duoderm
• Seals

• One piece appliance suitable for skin folds and
  dips, flexible.
• Paste levels pouch area to improve adhesion.
• Seal and wafer to creases if paste not effective.
• Wipes help protect surrounding skin.

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Many thanks from Fiona and Alison Remember
the Irish English DUO!

• GUINNESS COLOURED
• (Stop!)
• PINK CHAMPAGNE
• (Good)

Any Questions ?