Initial Cares

Follow the steps below to promote wound healing.

Steps	Action
1	Observe colour of blind end of 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 is there is >30-49mls/kg/day stoma output.
3	Ensure the skin surrounding the stoma is protected from excoriating effects of enzymes by: Covering area around stoma with orobase paste including wound/suture line and around the edge of the stoma. Covering the stoma with Paraffin gauze. Covering the Vaseline with dry gauze. Secure by applying base tapes on either side of the dressing and tapping onto these to reduce skin trauma. 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. As soon as the baby starts passing enough bowel motion so that it is getting onto surrounding skin, a stoma bag needs to be applied. This is usually 2-4 days post-op. 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 bag applied).

Stabilising the Stoma

Follow the steps below to ensure stoma is stabilised.

Steps	Action
1	Stoma bag must be changed as soon as it leaks.
2	Check flange and bag with cares, ensure flange is not leaking, if the flange is stained underneath then it has leaked and needs to be changed. Bag needs to be emptied when 1/3 full of bowel motion or gas as it will lift the flange.
3	To change bag if leaking: Gather equipment: gloves, bowl, warm water (no soap), gauze, orobase paste, cotton buds, appropriate sized bag and clip, scissors, stoma size gauge or last flange backing for size, non sting spray, adhesive stoma paste or powder. Carefully remove old bag 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. 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. Warm flange between hands for approximately one minute. Apply orobase to the edge of the hole cut in the flange with a cotton bud and to any excoriated areas. Apply flange and apply pressure to the flange for one minute and press down all edges. Check the flange is attached well. Close end of pouch with clip provided.

For further information on stomas, contact the Starship Ward 24B Nurse Educator.

Follow the steps below when doing a distal end washout.

Steps	Action
1	A contrast study may be requested prior to closure of the stoma, as per individual surgeon orders.
2	Ensure that warmed 0.9% sodium chloride 10ml/kg is used.
3	With a size 8 feeding tube lubricated with KY jelly, intubate the stoma 1-2cm or until there is resistance.
4	Flush saline through with a syringe using minimal pressure.
5	Fluid coming out through the rectum must be clear pre operative.

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