Enterostomy care

What is it?

An enterostomy or ostomy (colostomy, ileostomy) is a surgically created opening of the bowel (intestine) to the outside which allows the body to empty stool (poop) and gas. The end of the intestine, which is brought to the surface of the skin on the abdomen, is called the stoma.
An enterostomy can be temporary or permanent.

Your child has no control over the output of stool or gas through an enterostomy.
The stool (poop, bowel movements) can be:
- liquid, semi-liquid or pasty (usually seen with an ileostomy),
- solid or semi-formed (usually seen with a colostomy).
Several factors can influence the consistency of the stool.
The location of the stoma influences the consistency of the stool. The further away from the anus (where stool usually exits the body), the more liquid the stool tends to be.
The amount and frequency of output through a stoma depends upon many factors, including your child’s diet and activity.
A healthy stoma looks like a round/oval opening with skin that resembles the inside of the mouth (moist and dark pink/red).
When your child cries, the stoma can change colour from pale to dark red or even purple; the colour should return to normal once your child is calm.
The ostomy opening may be swollen for up to 6-8 weeks after the surgery. The swelling usually decreases after this time.
From the surface of the abdomen, a stoma may appear to be:
- slightly below the level of the skin (retracted),
- at the level of the skin (“skin-deep”),
- on top of the skin (outside or external to the skin), protruding/sticking out slightly (1-2 cm) or protruding moderately (more than 2 cm).
A stoma may also stick out like a telescope; this may be called a herniation or prolapse.
The diameter and shape of a stoma may vary.

Any change in the diameter, shape or length of your child’s stoma should be discussed with your healthcare team.
The skin on the inside of the stoma is fragile; it can bleed slightly when touched but is not usually painful or sensitive.
You may notice that the stoma can vibrate or move slightly. This is the normal movement of the intestines, called peristalsis, which normally propels the stool towards the rectum and anus, the usual exit from the body. Your child has no control over the peristalsis.

What happens to the remaining portion of the intestine?

During surgery, the rest of your child’s bowel/intestine, that is, the part that comes after the stoma, may be removed or not, depending on your child’s specific problem.

If the rest of the bowel is kept, it may be:

sewn closed and left in the abdomen (Hartmann sac) or,
may be redirected outside of the body via a second stoma (called a mucous fistula).

When there is a section of remaining intestine in the body, it naturally produces some secretions (mucous).

This may be removed from the body via the mucous fistula or, if your child still has a natural rectum and anus, the mucous may come out like a bowel movement, either in the diaper or in the toilet, depending on the age of your child.

How does it work?

An enterostomy allows gas and stool (poop) to pass directly from the intestine into a collection device (called a stoma appliance or stoma pouching system) that your child wears on the abdomen.

The stoma appliance has two specific roles:
- it collects the stool,
- it protects the stoma and the skin around the stoma.
The stoma appliance has two parts:
- a collection bag/pouch to hold the stool and gas,
- a skin barrier (also called a wafer or skin protector) that sticks to the skin and around the stoma to protect this fragile skin.
These two parts of the stoma equipment may be joined together (one piece) or separated (two pieces) depending upon the model recommended by your child’s healthcare team.
If they are separate pieces, then the skin protector part has a raised portion (called a flange). The flange is used to secure the collection bag to the skin protector without putting pressure on the actual stoma. The collection bag clips onto the flange like a lid on a plastic container.

There are many different models and sizes of stoma appliances. Your child’s healthcare team will help select the type that will suit your child best. You may need to try a few different models out to find the one that works best for your child.
The collection bag may be either closed or drainable.
- The closed bags do not have an opening. They should be discarded when they are approximately one third filled; this type of bag is rarely used in children.

The drainable bags allow for the contents to be removed from an opening in the bottom and then to be resealed shut to use again. The bag should be emptied when it is one third full. The bag stays attached to the flange and the skin protector; it does not need to be removed to empty the bag. The drainable bags close at the bottom using a clasp which can be either part of the bag or a separate piece.

Either type of collection bag (closed or drainable) can be used with a internal disposable bag (called a pouch liner), which is often appealing to teenagers who have enterostomies because it is easy to empty and easily replaced with a new one. The pouch liner is removed when it is one third full and the contents can be flushed down a toilet.

The collection bags can be either transparent (clear) or opaque (can’t see through them). Some models have a filter that removes air without releasing odours.

The stoma appliance is changed every 3 to 7 days but the frequency will vary according to the specific needs of your child. Speak with your enterostomal therapy nurse or child’s healthcare team to know how often your child’s appliance should be changed.

FAQ – Enterostomy care

When to consult your healthcare team

Equipment

You are having difficulties with the equipment.
There is an ongoing leakage.

Skin around the stoma

The skin is irritated (ex: redness, red bumps, small injuries, itching, burning), and you have not been able to resolve the problem.

Stoma

The stoma changes color for more than a few minutes.
The stoma has sunk in or sticks out more than 0.5 cm from its usual position.
There is bleeding (more than a few drops).

Stool

The amount of stool has increased or decreased more than usual, for more than a day and for no apparent reason.
Your child has persistent diarrhea (more water loss in the stool).

General state of health

Your child has abdominal pain or swelling.
Your child has signs of dehydration:
- less frequent urination (wet diapers) /more concentrated (dark yellow) urine;
- dry lips and mouth;
- sunken eyes;
- headache, feeling faint, dizzy or tired;
- faster heart rate.
Your child has nausea, vomiting or unexplained pain.
Your child has a fever (≥ 38⁰C rectal or ≥ 37.5⁰C oral or ≥ 37.5⁰C armpit).

Do not hesitate to contact your enterostomal therapy nurse or your healthcare team with any specific questions concerning your child.

WARNING: The information in this section is meant as a general guide to help parents and caregivers with common issues and is not intended to replace the care provided by your child’s healthcare team.

Discuss your child’s unique needs with your healthcare team, including WHO and WHEN to contact when problems arise.

Watery stool

Possible cause(s)

The body has difficulty in absorbing water
Reaction of the body to certain foods or medications
Infection

What to do?

The stool of an ileostomy may be liquid or pasty, and that of a colostomy may be semi-formed or formed.
Talk with the nutritionist about foods that can change the consistency of your child’s stool.
You can put a few cotton balls or an absorbent tampon into the collection bag to absorb the excess liquid and this will also make emptying easier.
Powdered fibers (eg, “Metamucil”) can be added to the bag so that the content can become jelly-like.
It is particularly important if your child has an ileostomy, that you ensure your child drinks more than usual in order to prevent dehydration.
If liquid stool is not normal for your child, or if there are more than usual, it is important to consult your healthcare team immediately.

Constipation

Possible cause(s)

Certain medications/foods can constipate
Low fluid intake

What to do?

Children with colostomies may be constipated, ie, no bowel movement for two or more days.
Ensure that your child drinks enough as recommended by the healthcare team.
See the nutritionist or a member of the healthcare team if necessary.

Irritated skin around the stoma: red, swollen, burning, presence of small red bumps, small wounds or slight bleeding

Possible cause(s)

Leakage around the collection device
Injury caused by an ill-fitting device
Use of products irritating to the skin
Watery stool
Sweating

What to do?

The skin around the stoma of your child should look the same as the skin over the chest and abdomen.
It is important that the skin barrier fits closely to the stoma but without touching it.
Do not use products such as powder, lotion, ointment that may prevent the skin barrier from sticking well.
It can be challenging to avoid stoma irritation in the young child who is active and growing; speak with your enterostomal therapy nurse or your healthcare team as soon as possible as there are many special products that can be tried to solve your child’s specific problem.

Unpleasant odors

Possible cause(s)

Incorrect installation of the collection device

What to do?

Odor should not be a problem if the collection bag is closed properly and if the opening is kept clean after the bag has been emptied.
Certain foods can cause more gas. Speak to the nutritionist about this.
If the odor is strong, or it persists after emptying the bag, or while changing the collection device you can:
- use a bag with a filter.
- use an odor eliminator for toilets (put 1 drop in the water before you empty the contents of the bag there).
- clean the inside and outside of the bag opening with toilet paper or a damp washcloth.
- for bags that have a clasp, roll the edge of the bag down (creating a rolled edge like a turtleneck) before emptying.
- use an odor eliminator in the bag after emptying it, according to the manufacturer’s instructions.

Discuss other possible “home remedies” as needed with your enterostomal therapy nurse.

Skin protector does not stick properly to the skin

Possible cause(s)

Too much stool in the collection bag
Skin around the stoma is oily or wet
Improper fit of the skin protector for the stoma

What to do?

Empty the bag when it is 1/3 full or almost 1/3 full if you anticipate going out with your child.
Consult your enterostomal therapy nurse or your healthcare team if the skin around the stoma is irritated (eg, red, red bumps, small wounds).

Do not clean the skin around the stoma with products that might be oily or leave a residue (creams, soap). Use only those recommended in the section Everyday tips, Bathing.
Always dry the skin around the stoma after cleaning.
Use the appropriate equipment for your child, adjusted to the length of the stoma to ensure that the skin barrier sticks well to the skin.
Warm the skin barrier well in your hands before applying it.
Change the collection device.

Detachment of the bag

Possible cause(s)

Collection bag too full
Collection bag poorly attached to the collar
Excessive movement of collection bag

What to do?

Empty the bag when it is 1/3 full or almost 1/3 full if you anticipate going out with your child.
If the bag fills with gas quickly, you can use bags with filters that permit the passage of air.

Check whether the portion of the bag that fits the ring of the collar is secure.
Secure the bag under snug but not tight clothing, especially if your child is young and active.

Bleeding from the stoma

Possible cause(s)

Friction between the stoma and the skin barrier
Bleeding from the stoma itself or from inside the intestine

What to do?

The skin on the inside of the stoma is fragile; it is normal that it bleeds very slightly (a few pinpoint drops) when touched.
If appropriate, review how to cut the opening of the skin barrier, ensuring that the cut opening is smooth.
If there is significant bleeding, apply firm pressure to the site of the bleeding with a clean cloth or gauze; contact your healthcare team immediately.

Movement of the stoma: sinks inward or sticks out by more than 0.5 centimeters from its usual position

Possible cause(s)

Causes vary: may happen with increased activity, coughing, etc.

What to do?

The intestine can sometimes slide out through the stoma, like a hernia. Usually this does not cause pain.
Contact your healthcare team immediately.

For specific advice on your child or any other questions, do not hesitate to contact the enterostomal therapy nurse or your child’s healthcare team.

Everyday tips

Clothing

Cover the collection bag with clothing or the diaper. To stabilize the bag and reduce leaks, consider one piece outfits for young children.
Clothing should not be constrictive (too tight) as this will prevent the collection bag from filling correctly or may irritate the stoma (eg, trouser belt).
If your child tends to touch the stoma appliance, there are a variety of specialized accessories that may be of help; discuss this with your enterostomal therapy nurse or your healthcare team.

Bathing and swimming

Your child may take a bath or shower with or without the stoma appliance.
All of the stoma materials are waterproof. If your child bathes with the appliance in place, gently dry it with a towel or a hairdryer set to low or medium temperature.
The skin on the inside of the stoma is fragile; it may bleed slightly when touched.
Wash the skin around the stoma gently with warm water.
Do not use soap or oil-based products; they may leave a residue on the skin that prevents the skin barrier from sticking well around the stoma.
Do not use scented or chemically based products on the stoma; these can irritate or damage the skin.
Do not use baby wipes, baby oil, powders, ointments or lotions on the skin around the stoma.
If you still wish to use a cleanser other than warm water, select a mild, unscented soap (eg, “Dove”) or a gentle hypoallergenic cleanser (eg, “Spectro®” or “Cetaphil®”).
Rinse and dry the skin around the stoma before applying the skin barrier.
Your child may go swimming, with the collection bag on. Thoroughly dry after swimming, as indicated above.

Sleeping

Your child may sleep in any position; a healthy stoma is not painful.
Empty the collection bag before nap or bedtime; this way, there is less risk of leaks.
If your child is less than one year of age, put your child to sleep on their back.

Nutrition and hydration

Some children with a stoma have another medical condition which may limit their choices of food (eg, Inflammatory bowel disease). Check with your child’s healthcare team to see which types of food are allowed.
When introducing new foods, try one at a time so you can determine your child’s response.
Some foods can cause odors and excess gas (eg, raw cauliflower). Offer these to your child less often.
If your child has an ileostomy, smaller, more frequent meals are recommended (eg, 5-6 small meals per day).
When a child has a stoma, there may be a variation in the amount of water that is excreted with the stool. You will learn to recognize your child’s usual pattern.
Your child should drink frequently, especially if your child has an ileostomy. Increase water intake when your child has a fever, increased activity or when it is hot outdoors.
Know the signs of dehydration in children:
- less frequent urination (wet diapers) /more concentrated (dark yellow) urine
- dry lips and mouth
- sunken eyes
- headache, feeling faint, dizzy or tired
- faster heart rate.

Activities

Your child’s activities should not be limited by the stoma.
For safety reasons, consult your healthcare team before your child starts a new activity or sport.
It is possible to make a custom protection for your child’s stoma so that your child can participate in contact sports.

Travel and transportation

By car, make sure that the seatbelt does not compress the stoma or the collection sac. If needed, place a rolled towel between the waist and abdomen of your child to protect the stoma site.
By air, empty the collection sac more often. With changes in elevation and air pressure, air may expand and fill the collection bag more quickly. Keep extra stoma supplies with you on board the airplane in your carry-on luggage.
When travelling, plan to bring plenty of spare supplies, including a change of clothing and plastic zip lock bags for soiled items.
Check if your usual source of supplies has a distribution site in the region that you are travelling; this may be helpful if you need to purchase extra supplies in the case of an emergency.

Others

Infants (0-1 years)

During the first year of life, most babies grow a lot. The stoma may change size more often and you will likely have to try different types of collection systems to find the one that suits your child best.
At this age, babies are curious about their bodies and their environment. Occupy their hands with an interesting toy while handling the collection bag.

Toddlers (1-3 years)

These children are curious, quick and like to move. They may not wish to stay still while you are trying to provide care. Prepare all of your materials in advance and have the supplies ready nearby. This will allow you to provide the care more quickly.
It is at this age that it can be most helpful to have the help of another person when you are providing care.
Explain the care simply to your child and explore ways to encourage participation in the care.

Preschool (3-5 years)

These children are curious and interesting in being more independent. They can participate in simple tasks like washing the skin or removing the skin barrier.
Use short, simple explanations and instructions; these are best suited to their short attention spans.

School-age (6-12 years)

At this age, your child may wish to do more of the care. Encourage and support your child while they are learning how to provide their own care (eg, emptying the collection bag).
You will still want to keep an eye on the stoma site and to verify, at least once a week, that the site is in good condition.

Adolescents (13-17 years)

During this period of increased growth and activity, your teenager may need more hydration; encourage your child to drink plenty of fluids, especially during sports activities and when the weather is hot.
Adolescents are often sensitive about their appearance and shy, especially when there is something that is different about them. Respect your child’s wish for privacy as much as possible.
Do not hesitate to talk to your teen about relationships and intimacy; a mentor who has also lived with a stoma may be an important support.
Make sure your teen knows how to troubleshoot the common problems that may arise.
Encourage your teen to join a support group. There are lots of “YouTube” stories of adolescents and young adults with ostomies demonstrating how they do every day and unusual activities.

Methods of care

Methods of care : Emptying the bag of the stoma device

Indications

The steps in the method below may serve as a guide; speak to your healthcare team about the specific equipment that your child uses.

Considerations:

Each time the bag is emptied, it is very important to close it securely in order to prevent leakage and odor.
Optimize your child’s comfort during care with appropriate positioning and the use of distraction.

Frequency

Empty the bag when you find that it is 1/3 full of air/stool by gently feeling to see the amount it contains.

Depending on the age of your child, and the type of stoma, the bag should be emptied between 1-6 times per day. A bag that is overfilled can detach from the skin and cause leaks.
If the bag is filled with air, let the air out through the opening of the bag. If your child has a two piece device and there is very little stool in the bag let the air out by partially detaching the bag from the flange.

Required materials

Container in which to collect the stool (if the toilet is not going to be used directly)
Toilet paper
Washcloths and towels

Refer to your child’s healthcare team if the material or the sequence of steps you have been taught is different than those described.

Step 1: Anticipation

See the full description here

Summary:

Collaborate and form a team with your child. When you invest the time to form a strong team, children feel more comfortable and less anxious – this will help you complete the care with less stress – for you and your child.

Use these tips, from the start, to set the stage for a positive care procedure:

Create the right moment: integrate the care in a routine.
Alert your child to the needed care and communicate together.
Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

Step 2: Preparation

See the full description here

Summary:

Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

Step 3: Procedure

See the full description here

Summary 3 key concepts:

Safety: Carefully follow the care practice steps as you have been taught.
Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Step 4: Position your child

Place your child in one of the positions discussed with your healthcare team, according to age, ability to cooperate and comfort.
As soon as your child is able, place your child on the toilet seat.
If your child is older, your child may prefer sitting or standing in front or beside the toilet.

Why ?

This step makes the care easier.

Step 5: Open the bag

Direct the bag towards the toilet or container.
Put a piece of toilet paper on the surface of the water in the toilet.
If your child is lying down, put a towel or some other protection between your child and the bag.
Hold the bag, folding the bottom portion to keep the opening turned upwards.
For a bag with integrated closure:
- Open the bag by unrolling the closure.
- Put pressure with your thumb and your index finger on each side of the rigid part of the end of the bag in order to open it.

For a bag with a clasp:
- Open the bag by removing the clasp.
- Keep the clasp nearby.
- Fold over the edges of the end of the bag about 2-3 cms.

Why ?

This step helps avoid splashing of the bag contents, and keeps the materials clean, thus making the next steps easier.

Step 6: Empty the bag

Unfold the bottom of the bag, pointing the tip of the bag downwards and let the contents flow into the toilet or container.
Help empty the stool out of the bag, by sliding your fingers down the sides of the bag to push everything out.

Step 7: Clean the opening of the bag

Wipe the opening of the bag with toilet paper.
Clean inside as far as you can with toilet paper or a damp washcloth.
The manufacturers do not recommend using soap to clean the inside of the bag. The soap may reduce the ability of the bag to control odors.

Why ?

This step helps diminish odors and helps keep the outside of the bag clean.

Step 8: Drain the air from the bag

Slide your fingers down the outsides of the bag to empty out as much air as possible, before closing.

Why ?

This step helps to diminish odors and leakage from the bag. It also ensures that the bag can be closed more easily and fits better under clothing.

Step 9: Close the bag

Unfold the edge of the bag, then:
For a bag with an integrated closure:
- Roll or fold the edge of the bag according to the manufacturer’s instructions.
- Press firmly on the closure so that the seal is waterproof.
For a bag with a clasp:
- Put the clasp in place about 3 cm from the tip of the bag.
- Do not fold the bag more than once.
- Gently pull on the bottom of the bag to see that it is securely attached.

Why ?

This step stops stool from leaking out of the bag.

Step 10: Check the seal of the skin barrier

Check the skin barrier portion of the stoma appliance. There should be a tight seal of the skin barrier device to the skin of the stomach all around stoma.
Change the stoma collection device if you notice any of the following:
- Skin barrier is not well attached.
- There is leakage around the skin barrier or collection bag.
- The skin around the stoma appears irritated.
- Your child reports pain or burning around the stoma site.

Why ?

This step helps to identify quickly if there is any leakage around the stoma and thus prevent any skin irritation there.

Step 11: Recovery

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

Listen to what your child says about the parts of the procedure that were difficult or painful.
Comfort your child and recognize your child’s collaboration with positive feedback.
Highlight your child’s specific strengths that helped make the procedure positive.
Discuss with your child what might be done the same or differently the next time the care is needed.
Keep your promises if you have promised a reward, follow through.
Reward yourself too.

Methods of care : Changing the collection device

Indications

The steps in the method below may serve as a guide; speak to your healthcare team about the specific equipment that your child uses.

Considerations:

- This is an opportunity for your child to have a bath/shower; it is also a good time to inspect the stoma for any changes.
- Consider taking a photo of the stoma from time to time; if there is new irritation, then the “baseline” photo may be very useful in making an accurate comparison.
- The stoma and the skin around it are fragile. Be gentle when doing this care. Keeping the skin around the stoma healthy is important in ensuring that the skin barrier device sticks well and so that it is comfortable.
- Measure the stoma with the measuring guide for two weeks after surgery. If it remains the same size, then you can stop. If still changing, even slightly, continue to measure for 6 to 8 weeks after surgery. The stoma will stabilize in size and you should no longer have to measure it.
- If the stoma has an irregular shape, use the measurement that is largest in width and in length.

Optimize your child’s comfort during care with appropriate positioning and the use of distraction.

Frequency

Change the skin barrier regularly every 3-7 days.
You might need to change the skin barrier more often if:
- the skin around the stoma is irritated,
- the stool is often watery or liquid,
- the stoma is bleeding,
- there is leakage of the bag contents under the skin barrier,
- skin protector does not stick properly to the skin,
- your child reports pain, burning or a stinging sensation around the stoma site,
- your child is irritable for no obvious reason.

In these situations, contact your healthcare team promptly for recommendations specific to your child’s condition.

Try to change the collection device when there is less activity in the bowels, for easier cleaning.
- ileostomy: before a meal or a few hours after the meal.
- colostomy: bowel function is not as closely related to meal time; choose a time based on your child’s usual patterns.

Required materials

Appropriate collection device for your child: one piece collection device (bag with skin barrier) or two piece collection device (bag with skin barrier and flange). When buying skin barriers, add 10 mm to the size of your child’s stoma.

Bag closure (according to the type of bag)
Stoma paste
Container for used materials (garbage)
Washcloths and towels
Toilet paper
Mild soap without perfume or additives

If needed:

Stoma measuring guide
Pen
Small fine scissors (for precision cutting)
Cotton swabs (eg, Q-Tips)
Dressing tape
10cc needleless syringe to apply stoma paste (or other size to be agreed upon with your healthcare team)

Refer to your child’s healthcare team if the material or the sequence of steps you have been taught is different than those described.

Step 1: Anticipation

See the full description here

Summary:

Use these tips, from the start, to set the stage for a positive care procedure:

Create the right moment: integrate the care in a routine.
Alert your child to the needed care and communicate together.
Form a team with your child: Encourage autonomy by offering realistic choices such as the method of distraction. Stay tuned to your child. Manage pain and anxiety, using distraction and positioning for comfort.

Step 2: Preparation

See the full description here

Summary:

Prepare the environment: Identify a routine place for care. Close windows, doors and fans. Wash and dry the work surface and gather the needed materials for the care and to distract your child.
Prepare your child: Get help if needed. Position your child for comfort to receive the care and start to use the selected distraction method.
Prepare yourself: Find the right time when you are ready to provide the care safely. Review the list of care steps. Wash your hands.

Now that you are ready to start the care procedure, take the opportunity to encourage and praise your child.

Step 3: Procedure

See the full description here

Summary 3 key concepts:

Safety: Carefully follow the care practice steps as you have been taught.
Flexibility: Be ready to adjust according to your child’s reactions during the procedure. As needed, reposition or select an alternative distraction strategy. Follow your child’s pace and rhythm.
Collaboration: Reassure your child, verbally and non-verbally. Acknowledge your child’s emotions and reactions. Help your child differentiate between the different sensations during a procedure.

Step 4: Position your child

Place your child in one of the positions discussed with your enterostomal therapy nurse or your healthcare team, according to age, ability to cooperate and comfort.

Why ?

This step helps with the care.

Step 5: Empty the bag

Empty the bag.

Why ?

It is easiest to change the collection device when it is empty.

Step 6: Remove the collection device

Using one hand, gently pull the abdominal skin above the stoma upwards.
With the other hand, peel off the skin barrier from top to bottom.
If there is a reusable clasp, remove it and keep it close at hand.
Throw away the used device in the garbage.

Why ?

This step avoids unnecessary stretching the skin and prevents irritation.

Step 7: Clean the stoma and the skin around it

This step can be done in the shower or bath.

Gently wash the stoma and the skin around it with warm water and a washcloth.
Do not rub the skin too hard as the skin is sensitive.
Do not use baby wipes, oil, powder, ointment or lotion on the skin around the stoma.
Use cotton swabs (Q-tips) to gently clean the folds in the skin that are hard to reach.

Rinse with water and pat the skin dry well with a clean towel.
Check that the skin around the stoma is clean and completely dry before proceeding to the next step.

Why ?

This step helps keep the skin around the stoma healthy and ensures that the skin barrier will stick well to it.

Any stool, soap or oil residues that remain can prevent the device from sticking well and cause irritation to the skin.

Step 8: Examine the stoma and the condition of the skin around it

Examine the stoma and the condition of the skin around it. This should be in the same condition as the skin over your child’s stomach.
It is normal to see the markings left from the previous skin barrier (little pressure marks on the skin around the stoma) and occasionally to see a few small drops of blood on the stoma.
If the skin is red, swollen or your child complains of a burning sensation then the stoma is likely irritated.
If the stoma or the skin around looks different than usual, consult your enterostomal therapy nurse or healthcare team.

Why ?

This step helps to identify quickly if problems arise and thus helps prevent complications.

Step 9: Place a temporary absorbent protection over the stoma

Place toilet paper on the stoma to catch any stool that might come out during the procedure.
Keep this protection in place until you install the new device.

Why ?

This step keeps the stoma clean and dry in preparation for the next steps.

Step 10: Cut the opening in the skin barrier, if necessary

The barrier should fit closely to the stoma, without touching it.
Some skin barriers already have an opening cut that fits directly over the stoma. If this is the type of device that your child uses, go to step 12.
If the skin barrier has to be cut: using a pen, draw the stoma on the back of the barrier as measured using the measuring guide.

Using small fine scissors, cut the skin barrier to create the opening for the stoma and add 3 mm to the size of the stoma; for example, if the stoma measures 22 mm, cut the barrier at 25 mm.

Why ?

A well-fitting skin barrier protects the skin around the stoma.

Cutting the skin barrier a little bit larger than the stoma allows for the natural movement of the stoma with the passage of stool, without causing irritation.

Step 11: Smooth out the cut opening of the skin barrier

Using your finger, smooth around the edge that has been cut to ensure that there are no rough edges.
Do this carefully, without making the opening bigger.

Why ?

This step prevents a rough edge of a poorly cut collar from irritating the stoma or the skin around it.

Step 12: Warm the skin barrier

Place the skin barrier, still wrapped, on you or on your child to warm it up to body temperature.
You can use your hands, skin surface or another source of gentle warmth, for a few minutes to soften the skin barrier.

Why ?

This step helps the skin barrier stick better to the skin over stomach.

Step 13: Select the placement of the bag (one piece device)

If your child uses a two piece device, go to the next step.

Depending on the position that your child is usually in, place the bag as follows:

if your child is usually lying down (eg, an infant), then place the bag so that it is perpendicular to the thigh (for drainage to the side).
if your child is usually standing or sitting upright, then place the bag so that it drains downwards, parallel to the thigh.

Why ?

This step lets the bag fill more easily and ensures that the collection device is secure.

Step 14: Remove the plastic covering or the protective paper from the skin barrier

Why ?

This step allows you to proceed with the treatment.

Step 15: Protect the skin around the stoma

Check to see if the opening of the skin barrier is neatly trimmed and will fit properly.
According to the method recommended by your enterostomal therapy nurse or your healthcare team, apply the stoma paste in either of the following ways:
- a layer on the back of the skin barrier around the opening or
- a ring of paste around the stoma.
To better control of the amount of the paste to be applied around the stoma:
- take a 10 cc syringe without a needle,
- remove the piston/plunger,
- squeeze in the amount of paste you need through the large end of the syringe,
- replace the piston,
- push gently on the piston to release a precise amount of paste where it is required.

If your healthcare team recommends it, a special stoma powder can be used if the skin around the stoma is irritated and there is leakage.
For ileostomy: always use paste to prevent liquid stool from leaking.
For colostomy: use paste until your child is spending most of his/her time standing or sitting (around 2 years of age).

Why ?

The height of the stoma and the unevenness of the surface of the skin around the stoma can prevent the skin barrier from sticking well.

This step protects the skin by creating a seal between the stoma and the skin surface if it touches stool.

Step 16: Place the skin barrier around the stoma

Remove the toilet paper that was protecting the stoma.
Then, check the placement of the skin barrier before removing the adhesive film:
- hold the skin barrier by the edges,
- center it around the stoma,
- if it is a two piece device, consider the placement of the bag before you place it on the skin, perpendicular to the thigh of the child (draining to the side) for the child who is lying down on their back most of the time or parallel to the thigh of the child (draining downwards) for the child who is sitting or standing most of the time,
- place it on the skin.
Next, take off the protective film on the adhesive border of the skin barrier.
Using your finger and your hand, make circles around on the protective barrier around the stoma to make it stick well to the skin.
Gently press on the skin barrier for 1-2 minutes until the barrier sticks completely.

Why ?

This step helps prevent folds in the skin around the stoma and ensures the barrier will stick well. The bag is positioned for comfort and to reduce the risk that the device will detach and leak the contents of the bag.

Step 17: Secure the bag (2 pieces device)

If your child uses a one piece device, go to the next step.

Attach the collection bag to the skin barrier by fitting the bag around the flange of the skin barrier.
Gently squeeze the bag to the flange, by pressing the two layers together with your fingers, starting at one point and moving in a circular motion to secure the seal all around the stoma opening.

Why ?

This step is important to prevent leakage from the device.

Step 18: Empty air out of the bag

Slide your fingers down the outsides of the bag to empty out as much air as possible, before closing.

Why ?

This step helps to decrease odors and prevent leaking.

Step 19: Close the bag

Bag with an integrated closure:

Roll or fold the end of the bag according to the manufacturer’s instructions.
Press firmly on the closure so that there is a good seal to avoid leakage.

Bag with clasp:

Put the clasp about 3 cm from the open end of the bag.
Fold the bag once.
Pull gently on the bottom of the bag to make sure that it is securely attached.

Why ?

This step prevents leakage of stool.

Step 20: Check that the skin barrier is completely sealed to the skin

Check that the skin barrier is completely sealed to the skin.
Carefully look at the skin barrier. It should be well fixed to the skin surface throughout.
If necessary, you can tape the skin barrier in place.

Why ?

This step allows you to identify quickly if there is any leakage and thus to avoid any irritation of the skin.

Step 21: Recovery

See the full description here

Summary:

The treatment is finished. Wash your hands again.

Be prepared to recognize the challenges faced and to provide positive feedback. Help your child recognize his/her strengths. Acknowledge the collaborative teamwork.

Listen to what your child says about the parts of the procedure that were difficult or painful.
Comfort your child and recognize your child’s collaboration with positive feedback.
Highlight your child’s specific strengths that helped make the procedure positive.
Discuss with your child what might be done the same or differently the next time the care is needed.
Keep your promises if you have promised a reward, follow through.
Reward yourself too.

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